Long Term Disability Denial FAQ: Answers from a Disability Insurance Lawyer
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Q: I got sick or injured and can’t work—what do I do now?
A: If you’re unable to work because of an illness or injury, you may qualify for one or more types of disability benefits—but figuring out what applies can be overwhelming. The best next step is understanding what kind of insurance programs exist and how they relate to your situation.
Here’s a breakdown of what might apply:
Workers’ Compensation
If your condition is caused by your job—like a workplace injury or occupational illness—workers’ comp may cover your medical bills and lost wages.Only applies if your condition is work-related
Short-Term Disability (STD)
Offered by some employers, STD coverage kicks in soon after you stop working and can cover several weeks or months.Often transitions into LTD
Long-Term Disability (LTD)
LTD benefits typically begin after STD or SDI ends, replacing a portion of your income (usually 50–70%) if you can’t return to work. Most employer-provided LTD plans are governed by ERISA, a federal law with strict rules and deadlines.This is where many people run into claim denials—and where we step in.
Social Security Disability Insurance (SSDI)
A federal program for people who can’t work in any job due to a long-term disability. It often runs in parallel with LTD—but has a much higher bar and slower process.State Disability Insurance (SDI)
Available in states like California, SDI offers short-term wage replacement if you’re unable to work due to non-work-related illness, injury, or even pregnancy.Limited duration—usually up to 52 weeks
California SDI: Covers short-term disability and paid family leave. Up to 52 weeks.
New Jersey TDI (Temporary Disability Insurance): Also covers family leave.
New York DBL (Disability Benefits Law): Provides 26 weeks max of wage replacement.
Rhode Island TDI: One of the oldest programs. Covers medical and family leave.
Hawaii TDI: Requires private employer-provided coverage but is state-mandated.
Puerto Rico: Similar structure to New York’s.
Paid Family & Medical Leave (PFML) / Paid Medical Leave Programs
Combine disability with caregiving leave via state-funded systems:
Mandatory PFML in California, Colorado, Connecticut, Delaware*, Maine*, Maryland*, Massachusetts, Minnesota*, New Jersey, New York, Oregon, Rhode Island, Washington, and District of Columbia.
These programs include coverage for “your own serious health condition” (i.e., non-work injury/illness)
*Note: Some of these are planned to launch between 2026–2028
What Dorian Law handles—and what we don’t:
At Dorian Law, we focus on helping people fight denied or delayed claims for:
Long-Term Disability (LTD) through employer-sponsored plans
Group life insurance and accidental death (AD&D) benefits
We don’t directly handle:
Workers’ Compensation
SSDI applications
State Disability Insurance (SDI) claims
But we’re happy to refer you to trusted attorneys who do.
Q: What is long-term disability insurance and how does it work?
A: Long-term disability (LTD) insurance replaces part of your income if you’re unable to work due to illness or injury. After an initial waiting period—called the elimination period—you may begin receiving monthly benefits, typically 50–70% of your previous earnings. These benefits can last for years, sometimes to retirement age, depending on the policy. If your claim is denied or delayed, a disability lawyer can help you fight back.
Q: How do I know if I qualify for LTD benefits?
A: You may qualify if your medical condition prevents you from performing your job—or, under some policies, any job. Eligibility depends on your specific policy terms, medical records, and how your symptoms affect daily functioning. Common qualifying conditions include chronic pain, autoimmune diseases, mental health issues, cancer, and neurological disorders. If you’re unsure, we can review your policy and help you understand your rights.
Q: How long do I have to wait before LTD benefits begin?
A: Most LTD policies have a waiting period—called an elimination period—of 90 to 180 days. This means you won’t receive LTD benefits until that period has passed, and you must remain continuously disabled the entire time. Some people receive short-term disability (STD) benefits during this gap, if available. It’s important to document your condition early and continuously during the waiting period.
Q: Can I work part-time and still receive LTD benefits?
A: Maybe. Some LTD policies offer “residual” or “partial disability” benefits if you can work reduced hours but have a loss of income due to your condition. These benefits typically require proof of income loss and ongoing medical disability. Insurers often challenge partial claims, so it’s smart to consult a lawyer before returning to work while receiving benefits.
Q: What’s the difference between ‘own occupation’ and ‘any occupation’ disability?
A: “Own occupation” means you’re considered disabled if you can’t perform your specific job. “Any occupation” means you’re only disabled if you can’t perform any job you’re reasonably qualified for based on your training, education, and experience. Many LTD policies switch from “own occ” to “any occ” after 24 months—this is when insurers often try to terminate benefits. Legal help at this stage can be critical.
Q: Do I need a lawyer to file for long-term disability benefits?
A: You’re not required to have a lawyer—but having one can make a huge difference. Insurers often deny valid claims or delay payment. A disability lawyer helps ensure your application is complete, your medical records are strong, and your rights are protected. If you’re already struggling with a serious health issue, legal support can ease the burden and improve your chances of success.
Long-Term Disability (LTD) Claim Basics
Understanding Your Disability Insurance Policy
Q: What does ‘own occupation’ or ‘any occupation’ mean in my policy?
A: “Own occupation” means you’re considered disabled if you can’t perform the duties of your specific job—the one you were doing before you became disabled. However, the definition often says to look at how the job is performed in the local or national economy, not for your specific employer. In that case, if your employer requires you to do something that other employers don’t, your inability to do that item may mean you cannot do your job, but it does not mean you cannot do your occupation.
“Any occupation” means you’re only disabled if you can’t work in any job for which you’re reasonably suited based on your training, education, and experience. Many LTD policies start with “own occupation” for the first 24 months, then switch to “any occupation” to make it easier for insurers to deny continued benefits.
Q: What is a pre-existing condition exclusion?
A: A pre-existing condition exclusion allows the insurer to deny your claim if your disability is linked to a condition you were treated for shortly before your coverage began—usually within the 3 to 12 months prior. These clauses are especially common in group policies and are often misapplied. Even if the insurer claims your disability is excluded, a closer legal review may reveal that the exclusion doesn’t actually apply.
Q: What is the elimination period and how does it affect benefits?
A: The elimination period is like a waiting period—usually 90 to 180 days—between the start of your disability and the time your LTD benefits begin. You must remain continuously disabled during this period, and you won’t be paid for it. Most people use state disability, short-term disability, or sick leave during this time. If you return to work or don’t document your disability clearly during this window, the insurer may try to deny your claim altogether.
Q: What does ‘maximum benefit period’ mean?
A: The maximum benefit period is how long your LTD benefits can last. This is often to age 65 or your normal retirement age—but some policies cap benefits earlier depending on the condition. Many policies also limit coverage to 24 months for mental health claims or “self-reported” conditions like chronic pain or fatigue. Knowing your benefit timeline helps you plan and push back if the insurer tries to end benefits early.
Q: What are ‘exclusions and limitations’ in an LTD policy?
A: These are the fine-print rules insurers use to deny or restrict benefits. Common examples include:
Mental illness or substance use limits (often capped at 24 months)
Pre-existing condition exclusions
Coverage cutoffs for overseas travel
Restrictions for self-reported symptoms
Many denials are based on broad interpretations of these clauses. An experienced disability lawyer can review your policy and explain what’s enforceable—and what isn’t.
Q: Can I request a copy of my LTD policy or plan documents?
A: Yes—and you absolutely should. If your policy is through your employer and governed by ERISA, the plan administrator is legally required to provide the full policy and summary plan description upon written request. Don’t rely on the insurer’s letters alone—they may leave out critical information. If you’re not sure how to request your documents or interpret what you receive, we can help.
Disability Insurance Company Tactics
Q: Why is the insurance company sending me to their doctor?
A: Insurers often schedule an Independent Medical Examination (IME) to evaluate your condition—but these exams aren’t truly independent. The doctors are hired (and paid) by the insurer, and they often write reports that favor denial. You don’t have to go unprepared. We advise clients on how to handle IMEs, what to expect, and how to challenge biased results.
Q: Can the insurance company surveil me or monitor my social media?
A: Yes—and they often do. Disability insurers use video surveillance, online searches, and social media monitoring to find anything they can spin as “proof” that you’re not disabled. Even ordinary activities (like walking your dog or attending a wedding) can be misrepresented. We help clients avoid common surveillance traps and respond when insurers cross the line.
Q: What is a functional capacity evaluation (FCE), and should I do it?
A: A Functional Capacity Evaluation is a series of physical tasks designed to test your ability to work. While some FCEs are legitimate, insurers often use them selectively to justify ending your benefits. If your insurer requests one, talk to a lawyer first—we’ll help you evaluate the risks, prepare appropriately, or challenge the request.
Q: The disability insurance company says I can do “sedentary work”—what is that? I know I can’t work. What now?
A: This is one of the most common LTD tactics. Insurers often say you can return to work in a “sedentary” job based on vague job descriptions or skewed medical reviews. But they ignore real-world limitations like pain, fatigue, or cognitive dysfunction. We counter this by building detailed medical records and vocational evidence that show the full picture.
Q: What if I missed a deadline because the insurance company delayed things?
A: Insurers sometimes create confusion or drag things out until you miss an appeal deadline. While ERISA deadlines are strict, courts may forgive delays caused by misleading communications or administrative failures. If you’re in this situation, contact a lawyer immediately—we may still be able to preserve your rights.
Q: Why do disability insurers make the process so hard?
A: Unfortunately, many insurers make money by denying claims. They use complex policy language, narrow definitions of disability, paid reviewers, and delay tactics to discourage claimants. The system isn’t designed to be fair—it’s designed to be efficient for them. That’s why having an experienced disability attorney can make all the difference.
Disability Claims Through Work (ERISA Legal Issues)
Q: Why are disability claims through work so complicated?
A: Most employer-sponsored disability plans are governed by a federal law called ERISA. It limits your legal rights, shortens your deadlines, and usually requires a detailed administrative appeal before you can sue. You don’t get a jury, there’s no emotional distress damages, and you only have one chance to submit evidence. This makes ERISA claims more technical and less forgiving than individual policies.
Q: Is there a difference between employer disability plans and private policies?
A: Yes, and it’s a big one. Employer disability plans are usually controlled by ERISA, a federal law that heavily favors insurers. In contrast, individual or private disability policies fall under state law—which may give you broader rights, including jury trials, bad faith claims, and more expansive damages. The rules that apply to your claim depend on how you got your coverage, not the nature of your disability.
Q: Who decides if an insurance denial was wrong?
A: In ERISA cases, you need to file an appeal. Usually the appeal is decided by the same entity that already denied your claim (sound like a conflict of interest to you?). If you need to file a lawsuit, the court decides, not a jury. The judge in your case may apply either a de novo standard (fresh review) or an abuse of discretion standard (giving deference to the insurer’s decision). This “standard of review” can be the difference between winning or losing your long term disability lawsuit. Which one applies depends on your plan language and state law. For example, in California, many plans no longer allow discretionary clauses—so judges review the case independently, without giving the insurer the benefit of the doubt.
Q: Who do I sue if my disability claim is denied?
A: Under ERISA, you usually sue the plan administrator, which may be the insurance company, your employer, or both. Identifying the correct defendant is important. You can't sue for emotional distress or punitive damages—but you can seek back benefits, interest, and potentially attorney’s fees. A lawyer can help you name the right parties and build a compelling case.
Q: What can I recover if my insurance company denies my claim?
A: In ERISA disability cases, your recovery is limited to the benefits you were wrongly denied, plus interest and, in some cases, attorney’s fees. You generally can’t get pain and suffering or punitive damages—even if the insurer acted in bad faith. That’s why building a strong claim record during the appeal is essential: it may be your only shot to prove your case.
Q: Do I need a lawyer for a disability claim under my employer’s plan?
A: You’re not required to have one—but ERISA claims are full of legal traps. If you miss a deadline, skip a key piece of evidence, or don’t understand the policy terms, your claim could fail—even if you’re truly disabled. A lawyer with ERISA experience knows how to build your case, navigate the procedural landmines, and maximize your chances of success.
Long Term Disability Denials and Appeals
Q: Why was my long-term disability claim denied?
A: Insurers often deny claims for reasons like “insufficient medical evidence,” “pre-existing condition exclusions,” or claiming you can still work. Many denials are based on biased reviews, surveillance, or paper-only assessments. A denial doesn’t mean your case is over—it means it’s time to fight back.
Q: What should I do immediately after an LTD denial?
A: Read the denial letter carefully and don’t delay. Under ERISA, you typically have 180 days to appeal. Request your claim file from the claim administrator and plan documents from the plan administrator right away as both have 30 days to respond. ERISA or not, start gathering medical records, doctor statements, and other supporting evidence. Don’t call the insurer without understanding your rights—a lawyer can help you build a strong appeal from day one.
Q: How long do I have to appeal an LTD denial?
A: If your claim is governed by state law, there may not be a deadline (even if the insurance company says there is). If ERISA applies, you generally have 180 days from the date of the denial letter to submit your administrative appeal. Missing this deadline can permanently bar you from suing in court. Even if you’re overwhelmed, don’t wait—legal help can take the burden off your shoulders and keep you on track.
Q: Can I submit new medical evidence during my LTD appeal?
A: Yes—and you should. Under ERISA, your appeal is often your last chance to add new evidence before litigation. That includes updated records, test results, doctor declarations, and even personal impact statements. A strong appeal package increases your chances of reversal without a lawsuit.
Q: What if my insurance company says my condition is ‘not disabling enough’?
A: This is a common tactic. Insurers may downplay your symptoms, cherry-pick medical notes, or rely on non-treating consultants. But disability isn’t just about diagnosis—it’s about how your condition affects your ability to work. A lawyer can help reframe the narrative and expose flaws in the insurer’s reasoning.
Q: What are my chances of winning an LTD appeal with a lawyer?
A: Your chances improve significantly. A skilled ERISA attorney knows how to present the right evidence, navigate policy loopholes, and anticipate insurer tactics. Many denials are overturned on appeal when handled properly. Even if you eventually have to sue, a strong appeal record sets the foundation for success.
Disability Insurance Litigation and Settlements
Q: Can I sue the insurance company for denying my disability insurance claim?
A: Yes—but in many cases, especially under ERISA, you must first go through a mandatory appeal process. Only after the appeal is denied can you file a lawsuit in federal court. If your policy isn’t governed by ERISA (like an individual policy), you may be able to sue sooner—and potentially seek additional damages like bad faith or emotional distress. A lawyer can help you figure out when and how to take legal action.
Q: How long does a disability lawsuit against an insurance company take?
A: It depends. ERISA cases in federal court are typically resolved in 9–18 months, often through written briefs instead of trials. Non-ERISA lawsuits may take longer—especially if they involve jury trials or extensive discovery. The timeline also depends on how hard the insurance company fights and how overloaded the court is. We’ll give you honest expectations from the start.
Q: If I file an ERISA disability lawsuit, will I have to testify or go to court?
A: Not always. In ERISA disability cases, there usually isn’t a jury or trial—judges decide the case based on written evidence and legal arguments. You likely won’t have to testify. For individual policy denials outside ERISA, you may need to give a deposition or appear in court, but most cases settle before trial. If courtroom involvement becomes necessary, we’ll prepare you every step of the way.
Q: Can I settle my disability claim without going to court?
A: Yes—and many cases settle before a judge ever rules. Settlement can happen during the appeal process, after filing a lawsuit, or even in mediation. Insurers often negotiate once they realize you’re serious and well-represented. We’ll help you evaluate any settlement offers and decide what’s fair, based on your benefits, medical history, and legal leverage.
Q: How are LTD settlements calculated?
A: LTD settlements typically reflect the present value of your future benefits, minus what’s already been paid. Insurers consider factors like your age, medical prognosis, occupation, and the strength of your claim. Settlements are often less than the full policy value but provide a lump sum and closure. We negotiate aggressively to ensure you’re not shortchanged.
Q: What happens if the insurance company refuses to settle?
A: If negotiations fail, we move forward with litigation. For ERISA claims, this means filing a federal lawsuit and asking the judge to review the case based on the administrative record. For non-ERISA policies, we may take the case to state court. Either way, we prepare as if we’re going to trial—because insurers take you more seriously when they know you’re ready to fight.
Working with Dorian Law on Your Disability Insurance Claim
Q: What kind of disability insurance cases does Dorian Law handle?
A: We represent individuals whose long-term disability (LTD) benefits were denied, delayed, or terminated—especially through employer-provided plans governed by ERISA. We also handle claims under private, individual LTD policies. Whether your insurer is Unum, MetLife, Prudential, Hartford, Lincoln, New York Life, or another company, we know how they operate—and how to fight back.
Q: When should I contact a disability insurance lawyer?
A: As early as possible. You don’t have to wait for a denial. We can help with:
Preparing or reviewing your initial LTD claim
Responding to requests for more information
Appealing a denied or terminated claim
Even if you’re still on benefits, we can advise you on what to expect. The sooner you involve a lawyer, the more options you may have.
Q: What does it cost to hire Dorian Law for a disability claim?
A: We handle many LTD cases on a contingency fee, which means you pay nothing upfront—and we only get paid if we win. If your claim involves court filings, we advance the costs. You’ll never be surprised by fees, and we’ll explain everything before you sign anything. Others like the option of paying for our services on an hourly basis. If presented with both, neither option is “better,” and the decision will be yours.
Q: Will I work directly with an attorney, or just staff?
A: At Dorian Law, your case is led by an experienced disability attorney, not just passed off to non-lawyers. You’ll have a clear point of contact and personal attention throughout your case. We pride ourselves on accessibility, clarity, and responsiveness—because this process is hard enough already.
Q: Can you still help if I live outside of California?
A: Yes. ERISA disability cases are based on federal law, so we can represent clients nationwide. We’ve helped claimants across the country go up against major insurers. If your case involves state law or a local court where we’re not admitted, we’ll let you know right away and can often find local counsel to help us handle your case or refer you to a trusted colleague.
Q: What makes Dorian Law different from other disability lawyers?
A: We don’t dabble—we focus almost entirely on disability and life insurance claims. We know the policies, the insurers, and the tactics they use to avoid paying. We combine deep legal expertise with a client-first approach: strategic, compassionate, and relentless. These help explain why Dorian Law’s attorneys have an impressive track record of success. When the insurance company says no, we help you say: not so fast.