Why Long-Term Disability Claims Fail: A Litigation Perspective

A long-term disability (LTD) claim denial can feel like a dead end, especially when you are dealing with a serious medical condition and relying on those benefits to pay your bills. But a denial is not the final word. Many long-term disability denials are the result of insurance company tactics that can be challenged with the right legal strategy and the right evidence. At Monahan Tucker Law, our disability attorneys have helped policyholders who live in or are employed by corporations based in Washington, California, Oregon, Arizona, and Nevada overturn wrongful denials and recover the benefits they were promised.

A long-term disability claim denial occurs when an insurance company determines that a claimant does not meet the policy’s requirements for receiving ongoing disability benefits, or when the insurer terminates benefits that were previously approved. Denials can happen at the initial claim stage, during periodic reviews, or when the policy’s definition of disability changes from “own occupation” to “any occupation.” In each case, the insurer cites specific reasons for the decision, and those reasons can often be rebutted with targeted evidence.

This guide examines the most common reasons LTD claims fail and explains what you can do to fight back.

Why Your Long-Term Disability Claim Was Denied

Insurance companies deny and terminate long-term disability claims for a range of reasons, but certain patterns appear again and again. Understanding these patterns can help you identify what went wrong with your claim and how to address it on appeal.

Insufficient Medical Evidence

The most frequently cited reason for LTD denials is that the insurer concluded the medical evidence does not adequately demonstrate how your condition prevents you from working. It is the burden of the insured to prove with a preponderance of the evidence that the insured is disabled. Insurance companies, and courts,  require detailed, specific documentation that connects your diagnosis to measurable functional limitations. General statements from your doctor indicating that you “cannot work” are not enough. Insurers look for objective evidence such as diagnostic imaging results, laboratory reports, functional capacity evaluations, and detailed physician narratives explaining how your condition restricts specific work activities. Policies also regular that the insured be under the “regular” care of a physician, which usually means seeing a physician for the disability every few months, and complying with treatment plans.

Failure to Meet the Policy Definition of Disability

Every LTD policy defines “disability” in specific terms, and the definition often changes over the course of a claim. Usually during the first 24 months of benefits (depending on the policy), most plans define disability as the inability to perform the material duties of your own occupation. After that period, the definition typically shifts to the inability to perform the duties of any occupation for which you are qualified by education, training, age, and experience.

This transition, sometimes called the “own occupation” to “any occupation” switch, is one of the most common points at which insurers terminate benefits. Even if your condition has not improved, the insurer may argue that you are capable of performing some type of sedentary work and therefore no longer meet the policy’s definition of disability.

Where our clients are typically engaged in highly cognitive work, the disabilities our clients face tend to involve cognitive issues.  In these situations, we take the position that the same cognitive issues disabling our clients from their own occupation will disable them from any other occupation they could perform based on their education, training, age or experience. 

Pre-Existing Condition Exclusions

Many LTD policies include a pre-existing condition limitation that excludes coverage for disabilities arising from conditions that were diagnosed or treated within 90 days prior to the start of the insurance coverage. Note, this exclusion is only applicable if you become disabled in the first 12 months of your coverage. If your insurer determines that your current disability is connected to a condition you had before coverage began, and your coverage began less than 12 months before becoming disabled, they may deny your claim based on this exclusion. These determinations are sometimes aggressive, connecting your disability to prior medical history in ways that may not be medically accurate.  Our firm has an excellent track record of getting these pre-existing condition exclusion denials overturned, as the insurer rarely is careful in its analysis of what caused the medical issue requiring care in the 90-day period prior to coverage compared to what caused the disability.

Failure to Follow Prescribed Treatment

If you are not receiving regular medical care, have stopped treatment, or have declined a recommended procedure or medication, the insurer may deny your claim on the basis that your condition could improve with proper treatment. This reasoning applies even when the claimant has valid reasons for not pursuing a particular treatment, such as discontinuing medication due to severe side effects, or financial barriers to care.

Surveillance and Social Media Investigations

Insurance companies routinely hire investigators to conduct video surveillance of claimants and monitor their social media accounts. This surveillance does  not just look at your social media presence, but that of your friends and family, who may tag you in posts or photos even if your own account is shut down or private. If surveillance footage or social media posts show you engaging in activities that appear inconsistent with your stated limitations, the insurer may use this evidence to deny or terminate your claim. A photo of you at a family event, a short walk captured on video, or a post about a hobby can all be taken out of context and used against you. These investigations often do not account for the difference between brief bursts of activity and sustained functional capacity.

Missed Deadlines and Incomplete Documentation

The claims process involves numerous forms, deadlines, and documentation requirements. Failing to submit required paperwork on time, not responding to insurer inquiries within the designated timeframe, or submitting incomplete forms can give the insurer grounds to deny your claim on a procedural technicality, even when the underlying medical evidence supports your disability.

Reliance on Biased Medical Reviews

Many denials are driven by the opinions of physicians hired by the insurance company to conduct peer reviews or independent medical examinations (IMEs). These reviewers may never examine the claimant in person, relying instead on a selective review of the medical records. Their reports frequently minimize the severity of the claimant’s condition or contradict the opinions of treating physicians who have seen the claimant over months or years. When these insurer-retained opinions become the primary basis for a denial, challenging the reviewer’s qualifications, methodology, and conclusions is a key part of any appeal strategy.

What to Do After a Denial

If your long-term disability claim has been denied or your benefits have been terminated, act quickly. In claims governed by ERISA, you typically have a limited window (often 180 days) to file an administrative appeal. Missing this deadline can permanently eliminate your ability to challenge the denial.

After receiving a denial letter, take these steps:

• Keep copies of everything you have submitted to the insurer and everything they have sent to you.
• Request a complete copy of your claims file from the insurance company.
• Review the denial letter carefully to identify the specific reasons cited.
• Ask your treating physicians to provide updated records and detailed statements addressing the insurer’s stated reasons for denial.
• Contact a long-term disability attorney before filing your appeal.

Monahan Tucker Law Will Fight to Appeal Your Claim Denial

The appeal stage is the most critical phase of a long-term disability claim. In ERISA-governed cases, the evidence submitted during the appeal becomes part of the administrative record, which is typically the only evidence a federal court will consider if litigation becomes necessary. Getting the appeal right is essential.

At Monahan Tucker Law, the firm’s disability attorneys, Stacy Monahan Tucker and Carolyn Spencer, work with clients to build appeals that directly address the insurer’s stated reasons for denial, fill gaps in the medical evidence, and create a record that can withstand court review. The firm handles both ERISA and non-ERISA disability insurance claims, appeals, and litigation across Washington, California, Oregon, Arizona, and Nevada.

Monahan Tucker Law’s approach to long-term disability appeals includes obtaining targeted medical opinions from treating physicians and specialists, identifying errors and inconsistencies in the insurer’s review, and ensuring that the administrative record tells the full story of the claimant’s disability. The firm has a track record of successful outcomes in federal court, including victories against major insurance carriers that wrongfully denied or terminated benefits.

If your long-term disability claim has been denied or your benefits have been cut off, do not assume the insurer’s decision is final. Request a consultation with Monahan Tucker Law to discuss your case and learn what options are available to you.

Frequently Asked Questions

1: What is the difference between “own occupation” and “any occupation” disability?

“Own occupation” disability means your condition prevents you from performing the specific duties of your job at the time you became disabled. “Any occupation” disability means your condition prevents you from performing the duties of any job for which you are reasonably qualified. Most LTD policies begin with an own-occupation definition and switch to any-occupation after 12 to 24 months, which is when many benefit terminations occur.

2: Can the insurance company terminate my benefits after approving my claim?

Yes. Approval of an LTD claim is not permanent. Insurance companies conduct periodic reviews of ongoing claims and can terminate benefits at any time if they determine you no longer meet the policy’s definition of disability. These reviews often coincide with the own-to-any-occupation transition or are triggered by surveillance results, updated medical information, or an independent medical examination.

3: How does video surveillance affect a disability claim?

Insurance companies hire investigators to observe and record your daily activities. If footage shows you performing tasks that appear inconsistent with your reported limitations, the insurer can use this evidence to deny or terminate benefits. It is important to follow your doctor’s restrictions at all times and to understand that brief activities captured on video may be presented without context about your overall physical capacity or the pain and fatigue you experience afterward.

4: Do I need a lawyer to appeal a long-term disability denial?

While you are not legally required to hire an attorney, the appeal stage is the most strategically important phase of an ERISA disability claim. The evidence you submit during the appeal may be all the court ever reviews. An experienced disability attorney can identify the weaknesses in the insurer’s denial, gather the right medical and vocational evidence, and present your case in a way that maximizes your chances of success.

5: What should I do if my insurer is relying on a biased medical review?

If your denial is based on a peer review or IME conducted by a physician retained by the insurer, your attorney can challenge the reviewer’s qualifications, examine whether they had access to your complete medical records, and obtain detailed rebuttals from your treating physicians. In many cases, the insurer-retained reviewer never examined you in person and relied on an incomplete review of your file. Monahan Tucker Law will also arrange for truly independent exams or testing to refute the inaccurate insurance review.

6: Can I file a lawsuit if my appeal is denied?

In ERISA cases, you must exhaust your administrative remedies, which is typically a required internal appeal, before you can file a lawsuit in federal court. Once the administrative process is complete, you generally have a limited time to initiate litigation. The lawsuit will typically be decided based on the administrative record, which is why building a strong record during the appeal phase and hiring counsel for your appeal is so important.  There is rarely any discovery allowed or witnesses permitted in the trial phase. The judge is limited to reviewing the claim file. When claimants handle their own appeals, they usually write a letter stating that the insurer failed to listen to the insured’s physicians. While this may be true, it does not constitute “new” evidence. The insurer will deny the appeal for the failure to provide new information, and a judge will be forced to agree because no new evidence was provided on appeal.  A good lawyer is not just preparing your appeal, she is preparing your file for litigation.