Long-Term Disability Claim Denied? How an ERISA Lawsuit Works, Deadlines, and Your Appeal

Most long-term disability insurance in the United States comes through employers. Those plans are governed by ERISA, the Employee Retirement Income Security Act of 1974. ERISA sets the rules for how claims are decided and gives workers a specific way to challenge a denial.

Under 29 U.S.C. 1132(a)(1)(B), a plan participant may sue "to recover benefits due to him under the terms of his plan" and to clarify rights to future benefits. The lawsuit asks a court to decide whether the insurer or plan administrator was wrong to deny, terminate, or reduce benefits. Federal courts have jurisdiction regardless of the amount in dispute.

Common reasons insurers give for denials include lack of "objective" medical evidence, a finding that you can do your own job or "any occupation," reliance on paid file reviewers who never examined you, surveillance or social media, pre-existing condition exclusions, and limits on mental health or self-reported conditions. Whether any of those reasons holds up depends on your plan's wording and your records.

This is not a class action. There is no group settlement to file for. Each denied worker brings an individual claim, usually after exhausting the plan's appeal process. For the difference, see class action vs individual lawsuit.

The Department of Labor's claims regulation, 29 CFR 2560.503-1, sets minimum rules for disability claims:

Step	Deadline
Initial decision	45 days after the plan gets the claim
Extensions	Up to 30 days, then another 30, with written notice
Your appeal	At least 180 days after the denial notice
Decision on appeal	45 days, extendable with notice

For disability claims, the plan must decide within 45 days of receiving the claim, may extend twice by up to 30 days each only with written notice explaining why, and must give you at least 180 days to appeal a denial. Check your denial letter for the exact appeal deadline, count from the day you received it, and do not miss it; a late appeal can end your case.

Rules added for disability claims filed after April 1, 2018 give you more protection. Denial letters must explain why the plan disagreed with your treating doctors, with its own experts, or with a Social Security disability decision you provided. Before denying an appeal on new evidence or a new rationale, the plan must give you that evidence free and time to respond. If a plan fails to strictly follow the disability claim rules, you may be treated as having exhausted the appeal process and can go to court.

It also helps to know who you are dealing with. Your employer usually sponsors the plan, but an insurance company or third-party administrator typically decides claims. The denial letter should name the plan, the claims administrator, and where to send your appeal. Send the appeal where the letter says, keep proof of delivery, and follow up in writing if you do not get a decision within the regulation's time limits. Missed deadlines by the plan can themselves help you, because a plan that fails to follow the disability claim rules may lose the right to insist that you finish its appeal process before suing.

You have at least 180 days from a denial to file your ERISA appeal, and that appeal is usually your last chance to add evidence.

You may have a strong case to review if:

• Your coverage came through your job, a union, or a professional association plan.
• Your treating doctors document limits that keep you from working, but the insurer relied on reviewers who never examined you.
• The insurer ignored or did not explain a Social Security disability approval. See our glossary entry on Social Security disability.
• Benefits were cut off at the switch from "own occupation" to "any occupation," commonly after an initial period set in the policy, without a real change in your health.
• The insurer missed deadlines, did not provide your claim file, or relied on new evidence without giving you a chance to respond.

You may be outside ERISA if you bought an individual policy yourself, or if the plan is a government or church plan. Those disputes usually proceed under state insurance and bad faith law, which can allow broader damages. Ask an attorney which rules apply before assuming.

Matching your evidence to the denial reason

Appeals work best when they answer the insurer's stated reason point by point:

• "No objective evidence." Add test results, imaging, and specialist notes, and ask your doctor to explain why your condition may not show on a test (common with pain, fatigue, and many neurological or autoimmune illnesses).
• "You can do your job" or "any occupation." Get a doctor's statement of specific limits (how long you can sit, stand, lift, or concentrate), consider a functional capacity evaluation, and get a vocational opinion comparing those limits with real job demands.
• "Our reviewer disagrees with your doctor." Ask your doctor to respond directly to the reviewer's report, especially where the reviewer never examined you.
• Surveillance or social media. Explain the context of any activity shown, such as a good day followed by several bad ones, and back it with records.

The regulation requires the denial letter to describe what additional material you need to perfect the claim and why. Use that description as a checklist, and make sure every item is addressed before the appeal record closes, because new evidence offered for the first time in court is often not considered.

A denial does not mean you are not disabled. It means the insurer decided your records did not meet its reading of the policy. The appeal is where you fix gaps in the record.

In an ERISA benefits case there is usually no jury, and the judge often reviews only the administrative record: the documents in the claim file when the insurer made its final decision. That makes the internal appeal your main chance to add medical records, doctor statements, and vocational evidence.

In Firestone Tire and Rubber Co. v. Bruch (1989), the Supreme Court held that denials are reviewed de novo, meaning without deference, unless the plan gives the administrator discretionary authority, in which case a deferential standard applies. Many plans now include that discretionary language, which makes the insurer's decision harder to overturn.

In Metropolitan Life Insurance Co. v. Glenn (2008), the Court recognized that an insurer that both decides claims and pays them from its own pocket has a conflict of interest, and courts must weigh that conflict as a factor when reviewing its decisions. Evidence that the insurer cherry-picked records or ignored a Social Security finding can make that conflict matter more.

Some states limit discretionary clauses. California Insurance Code section 10110.6 makes any clause reserving discretionary authority to the insurer in a disability policy covering a California resident void and unenforceable. Where a ban applies to an insured plan, the court may review the denial without deference. For how courts and procedure work more generally, see how to sue a company.

A successful ERISA benefits claim usually recovers what the plan promised: past-due monthly benefits, often with interest, and reinstatement of future benefits as long as you remain disabled under the policy. Under 29 U.S.C. 1132(g)(1), the court may, in its discretion, award reasonable attorney fees and costs to either party.

ERISA generally does not allow punitive damages or emotional distress damages in a benefits claim, which is a major difference from state bad faith lawsuits over individual policies. Many cases settle, sometimes for a lump sum that closes the claim in exchange for giving up future benefits. Before accepting a lump sum, understand how it interacts with Social Security, taxes, and any offsets in your policy.

Disability benefits are usually reduced by other income, such as Social Security disability benefits, which many policies require you to apply for. For how outside payments can affect public benefits, see whether a settlement affects SSI or Medicaid.

Because ERISA remedies are limited to the benefits themselves, fees, and costs, the value of a case is usually driven by three numbers: your monthly benefit, how many months are past due, and how long benefits could continue under the policy. An attorney reviewing a denial will typically ask for all three early.

ERISA does not set its own statute of limitations for benefits claims. Courts borrow a state law period, and many plans write in their own shorter limit.

In Heimeshoff v. Hartford Life and Accident Insurance Co. (2013), the Supreme Court enforced a plan provision requiring suit within 3 years after proof of loss was due, even though much of that time passed during the internal appeal. The practical lesson: your deadline to sue may start before your appeal ends. Find the "legal action" provision in your plan document.

• Administrative appeal: at least 180 days from the denial notice, per the regulation; your letter states the exact date.
• Lawsuit: the plan's contractual limit if reasonable, otherwise a state period borrowed by the court.
• Social Security: separate appeal deadlines apply; do not let one process distract you from the other.

Start your appeal well before the 180-day deadline so there is time to get doctor letters and testing into the record.

1. Calendar the appeal deadline the day you get the denial.
2. Request your full claim file and the plan documents in writing. The plan must provide relevant documents free of charge.
3. Read the denial reasons closely and answer each one with evidence: updated records, a detailed treating doctor letter about specific work limits, functional capacity testing, and vocational input.
4. Include any Social Security decision and ask the plan to explain any disagreement.
5. Respond to new evidence the plan sends you before it decides your appeal.
6. Keep copies of everything you send, with proof of delivery.

Because the appeal record usually becomes the court record, many people get legal help before they file the appeal, not after. Our guide to finding a lawyer covers what to ask. Related insurance pages include total loss car payouts and underinsured motorist stacking. Independent attorneys who handle ERISA disability cases can review a denial; a free case review takes about two minutes.