Long-Term Disability

How can I explain why I cannot work?

Medical records help describe your condition, treatment and restrictions. Your account of your work helps show what those restrictions mean in practice. A job title alone may leave out much of what you actually do.

For example, a desk job may involve sustained concentration, deadlines and long periods of sitting. Other work may require lifting, driving, standing or being reliably present for a shift. Explaining those demands makes it easier to understand why a symptom or restriction interferes with the job.

Describe what changed, what you can still do and what happens when you try to work. Include the effect of treatment or medication when it affects you.

What if the insurer says the medical evidence is not enough?

A denial may say the records do not support the restrictions claimed or do not explain why you cannot perform particular duties. Understanding that reason matters. Sending the same records again may leave the insurer’s question unanswered.

A useful review compares the reason given with the treatment records, the work involved and any medical opinions already submitted. It may reveal a missing record, an unclear description of a duty or a point that needs a fuller explanation.

How can I prepare for a conversation?

Bring your policy or benefit documents, the latest insurer letter and any decision you want explained. A short outline of your work, your condition and the claim so far is useful. You can also write down the questions that are causing the most worry.

It is fine if your papers are incomplete or the terms are unfamiliar. We can begin with what you have, explain what else may be useful and discuss the next step. The conversation should leave you with a clearer understanding of your situation and the decisions ahead.

How do I apply for benefits?

The policy or plan sets out how to make a claim. The application may ask for information from you, your medical providers and your employer. Keeping copies of what is submitted helps everyone understand which information the insurer has received.

If you have already begun, tell us what has been sent and what the insurer is still requesting. If you are preparing an application, we can review the forms and discuss how to explain the effect of your condition. You can also ask about a response date or a document you have been unable to obtain.

When will payments start, and how much will they be?

The answer depends on your coverage. A policy may have a waiting period before benefits begin, a formula for calculating payments and limits on how long they continue. It may also account for income or benefits from other sources.

A payment calculation should explain which earnings figure and policy terms the insurer used. If the amount differs from what you expected, comparing that calculation with your coverage can help identify the reason. A general percentage or timeline cannot tell you what your own policy owes.

Why does it matter whether coverage came through work?

Many employer disability plans are governed by ERISA, a federal law that sets requirements for benefit claims and appeals. Individual policies and some employer arrangements follow different rules. The name of the insurer alone does not settle which process applies.

That distinction affects how a denial is challenged and which deadlines need attention. If you have both an employer plan and an individual policy, bring both so each can be considered.

What can I do if the claim is denied?

Begin with the reason for the decision. A denial may concern the medical evidence, the policy’s definition, coverage or another requirement. A response should address the reasons actually given and the documents supporting them.

For a disability claim covered by ERISA, the appeal rules generally allow at least 180 days after you receive a denial or a decision to stop benefits. Other policies, later legal action and particular circumstances can involve different deadlines. The notice and governing documents need to be read together before calculating yours.

ERISA’s disability-claim rules also provide access, on request and without charge, to relevant claim documents. Reviewing that material can help explain the basis of the decision. We can discuss the available records, what an appeal would need to address and the time available to prepare it.

What if I was receiving benefits and they stopped?

A stopped-payment decision can be especially disruptive when you have been relying on that income. The new decision needs to be compared with the policy, the earlier approval and the current evidence. It may involve updated medical information or a different definition of disability under the policy.

Keep the new letter and any recent requests from the insurer. Tell us what changed, including treatment, work attempts or information you were asked to supply.

How does this relate to Social Security disability?

Social Security disability and disability insurance are separate claims with different requirements. A decision under one does not, by itself, explain entitlement under the other. Your policy may also address how other benefits affect its payments.

If you have a Social Security application, decision or payment notice, include it in the discussion. Reading the insurance terms alongside the Social Security information helps explain whether a decision or payment under one affects the other. Each claim still needs attention to its own evidence and deadlines.

What if I can do some work, but not my usual job?

Some policies include partial or residual disability benefits for a reduced ability to work or a loss of earnings. Other policies use different terms or require a particular kind of limitation. Being able to do a task occasionally does not, by itself, explain whether those provisions apply.

The useful details are what work you can do, for how long, how regularly and with what effect afterward. A reduced schedule, changed duties or an unsuccessful attempt to return may be part of that picture. The policy’s definition and benefit calculation still control the insurance question.

Before making assumptions about how work will affect payments, the particular coverage and any reporting requirements need to be understood. The practical goal is to connect the wording with the work you are actually able to manage.

Are there exclusions or limits I should understand?

A policy may exclude certain circumstances from coverage or limit the benefits available for a particular condition. An exclusion addresses what is not covered; a limitation can restrict a benefit that is otherwise available.

If a letter relies on an exclusion or limit, the exact provision matters. The decision should be compared with the complete policy, the medical information and the dates involved. A summary of the rule may leave out wording that changes how it applies.

This is also why another person’s claim may not be a useful comparison. Two people with similar diagnoses can have different coverage. Understanding your own terms provides a more reliable basis for deciding how to respond.

What if the insurer keeps asking for information?

An approved claim may still involve requests for updated medical or work information under the policy. A request can be routine, or it can raise a question about continued eligibility. The letter should make clear what is being requested and when a response is expected.

Keeping the request with a copy of your response helps show what was supplied. If a record is unavailable or a question is unclear, that is worth addressing rather than guessing at an answer. Tell us about any request you are having difficulty with so it can be considered alongside the coverage and the claim’s history.

What will it cost?

A Free Case Review costs nothing. Many disability insurance cases use a contingency fee, which means the attorney’s fee is a percentage of any recovery. Before you decide whether to hire us, we’ll explain the proposed fee, any payment due upfront and how case expenses would be handled. Depending on the agreement, you may be responsible for some expenses even if no attorney’s fee is owed.

Talk with us

If you have questions about long-term disability benefits, request a Free Case Review or call 844-327-5529.

Related reading: Denied or Ended Benefits · Disability Insurance FAQs · Understanding ERISA: Your Guide to Private Retirement and Health Plans · What’s the Difference Between ERISA and Individual Disability Insurance? · Why Was My ERISA Disability Claim Denied?.