ERISA Long-Term Disability Appeal

The situation

Rachel, 46, was a marketing director earning $7,800/month when she was diagnosed with relapsing-remitting MS. Her employer's LTD policy (through MetLife) should pay 60% of her salary, $4,680/month, after a 90-day elimination period. MetLife denied her claim, citing "insufficient objective medical evidence of functional impairment." Rachel has no idea what that means. Her family's first attorney consultation revealed: (a) she has 180 days from the denial letter to appeal; (b) the denial letter arrived 45 days ago; (c) all the evidence she needs to gather must be in the appeal itself, ERISA does not allow adding new evidence once the administrative record is closed; (d) MetLife hired a medical reviewer who never met Rachel to assess her file remotely. She has 135 days left and no roadmap. The attorney charges $450/hour consultation. For a case worth $4,680/month, an ERISA attorney might take it on contingency, but first Rachel needs to know she has a case.

Who receives this

Employees with employer-sponsored LTD insurance (most full-time employees at companies with 50+ employees) who have received a denial letter within the last 180 days. Specifically: people with monthly benefits of $1,500-5,000/month where the case is valuable enough to fight but potentially below the threshold where an attorney takes it on contingency immediately. Secondary: family members managing an appeal on behalf of a spouse or parent who is too ill to manage it themselves.

Why the agency will not advise you

LTD insurance companies profit from claim denials and from claimants not knowing their rights. Their denial letters are intentionally opaque (using legal terms like "own occupation definition," "any occupation definition," "objective medical evidence," "sedentary capacity"). They do NOT want a tool that decodes this language into actionable steps. The data barrier: ERISA appeal strategy varies by denial type (medical necessity vs. definition of disability vs. procedure) and by insurer (Unum uses different patterns than MetLife, who differs from Sun Life).

Key facts, with sources

• Under ERISA, most private LTD claimants have exactly 180 days from the date of their denial letter to file an appeal, missing this deadline by one day permanently waives the right to challenge the denial in court. ~25% of initial LTD claims are denied; most claimants (80%+) do not appeal. The most common reason: they don't know the process, miss the deadline, or can't afford an attorney. Source: How Long Do I Have to Appeal a Disability Denial? — DarrasLaw
• ERISA denials use specific legal language that corresponds to specific evidence requirements. A denial citing 'lack of objective medical evidence' requires different documentation than one citing 'own occupation vs. any occupation definition change.' Most claimants don't know these are distinct denial types requiring different responses. Source: Long-Term Disability Denial Appeal — A checklist of Do's & Don'ts — Kantor Law
• LTD insurance companies (Unum, MetLife, Sun Life, Cigna) operate specialized Claim Review Units that use medical reviewers, vocational assessors, and investigative teams on denied claims. These teams are not disclosed to claimants. Claimants are told simply that their claim was 'reviewed.' Source: How ERISA Impacts Long-Term Disability Appeals — Cavey Law

When to bring in a professional

Self-serve responses fit routine cases: clear facts, amounts a business can absorb, and a deadline still ahead of you. Bring in a licensed professional when the amount at stake is large relative to their fee, the facts are genuinely disputed, criminal exposure is possible, or the deadline has already passed. A short paid consultation to sanity-check your plan is often worth it even when you handle the filing yourself.

All sources for this guide

1. How Long Do I Have to Appeal a Disability Denial? — DarrasLaw
2. Long-Term Disability Denial Appeal — A checklist of Do's & Don'ts — Kantor Law
3. How ERISA Impacts Long-Term Disability Appeals — Cavey Law