How to Appeal a Denied Long-Term Disability Claim in Pennsylvania: A Step-by-Step Guide

Receiving a denial for your long-term disability claim can be a major setback, especially when you’re already struggling with a serious medical condition. However, a denial does not mean the end of your claim. If your insurer has denied your benefits, you have the right to appeal, and taking the right steps can significantly improve your chances of success. 

This guide will walk you through the process of appealing a denied LTD claim in Pennsylvania, ensuring you have the best opportunity to secure the benefits you deserve.

Step 1: Review the Denial Letter Carefully

When your claim is denied, your insurance company is required to send you a denial letter explaining the reasons. This letter will outline:

• The specific reasons for denial (such as insufficient medical evidence or a policy exclusion)
• The deadline to file an appeal (often 180 days from the date of denial)
• The evidence the insurance company considered in making its decision

Understanding the reasons behind your denial is the first step in building a strong appeal. If the explanation is unclear, you may need to request further clarification from the insurer or consult an attorney for guidance.

Step 2: Gather Additional Evidence

A successful appeal often hinges on providing more substantial medical and vocational evidence than what was initially submitted. Consider obtaining:

• Updated Medical Records: Request documentation from your healthcare providers detailing your diagnosis, treatments, and limitations.
• Doctor’s Statement: A written opinion from your treating physician explaining how your condition prevents you from working.
• Functional Capacity Evaluation: A physical or cognitive assessment that objectively demonstrates your inability to perform work-related tasks.
• Vocational Expert Opinion: A report from a vocational specialist outlining why you cannot perform your previous job or any other type of employment.

Insurance companies often deny claims due to a lack of medical evidence, so supplementing your appeal with additional documentation can strengthen your case.

Step 3: Submit a Formal Appeal

Your appeal must be submitted within the deadline stated in your denial letter. The appeal should be in writing and include:

• A detailed letter disputing the denial, addressing each reason given by the insurer
• Additional medical evidence, test results, and doctors’ opinions
• Witness statements from family members or colleagues who can attest to your limitations
• Any additional records, such as Social Security Disability approval if applicable

This step is critical because if your appeal is denied, you may have to take legal action, and the administrative record from the appeal process will be used in court.

Step 4: Consider Legal Representation

Long-term disability appeals can be complex, and insurance companies often look for ways to avoid paying claims. Having an experienced disability lawyer on your side can increase your chances of success. A lawyer can help:

• Ensure your appeal is thorough and persuasive
• Communicate with the insurance company on your behalf
• Prepare for potential litigation if your appeal is denied

Step 5: File a Lawsuit if Necessary

If your appeal is denied, you may need to take legal action. In Pennsylvania, you can file a lawsuit under the Employee Retirement Income Security Act if your policy is employer-provided. If you have a private LTD policy, your case may be handled differently under state law. An attorney can help you determine the best course of action.

Edelstein Martin & Nelson, LLP

Navigating the long-term disability appeals process in Pennsylvania can be overwhelming, but taking the proper steps can make a significant difference in securing the benefits you need. By thoroughly reviewing your denial letter, gathering strong medical and vocational evidence, and submitting a well-prepared appeal, you improve your chances of success. 

However, insurance companies often make the process difficult, and denial does not mean the end of the road. With the right legal guidance, you can fight back and protect your right to compensation.

At Edelstein Martin & Nelson, LLP, we understand how critical disability benefits are to your financial stability and well-being. Our experienced Philadelphia disability lawyers are ready to help you build a strong appeal and challenge unfair denials. Don’t face the appeals process alone. Contact us today at (215) 731-9900 for a free consultation, and let us help you get the benefits you deserve.