A long-term disability lawyer represents people whose monthly disability benefits have been denied, terminated, or delayed by an insurance company, under either a policy obtained through work or one bought privately.
Sounds simple and straightforward. Unfortunately, long-term disability cases are rarely easy. At Edelstein Martin & Nelson, LLP, our work centers on a question most claimants have never been asked: which kind of policy do you actually have? The answer decides your deadlines, your remedies, and where your case would be heard.
If your benefits stopped, you are not in a dispute about whether you are sick. Instead, you are battling over the wording of a contract, the contents of a file, and a set of deadlines that started running the day the denial letter was written.
What Long Term Disability Insurance Pays, and When
Long term disability insurance replaces part of your income when a medical condition stops you from working. You may think of it as a lump sum. It is actually a monthly payment, usually a percentage of your pre-disability earnings, that begins after a waiting period and continues for as long as you meet the policy’s definition of disability or until the policy’s end date arrives.
Three features of the contract do most of the work in any dispute. The first is the elimination period, the stretch of time you must be disabled before any money is paid, commonly 90 or 180 days. The second is the definition of disability, which is the heart of nearly every denial. The third is the offset provision, which allows the insurer to reduce your monthly payment by other income you receive, most often Social Security disability benefits.
The definition matters. An “own occupation” policy asks whether you can perform the material duties of the job you actually held. An “any occupation” policy asks a much harder question: whether you can perform the duties of any job for which your education, training, and experience qualify you.
For example, a dentist with a hand tremor may be plainly disabled under the first definition and arguably not disabled under the second, with no change in her medical condition at all.
Policies also carry limitations that cap how long certain claims can be paid. Conditions treated as mental or nervous disorders, and conditions the insurer characterizes as based primarily on self-reported symptoms, are frequently limited to 24 months of benefits regardless of how long the impairment lasts.
Such provisions are enforceable contract terms, not insurer inventions, which is why they need to be carefully read and assessed before a claim is filed rather than after it is denied.
Two Kinds of Policies, Two Sets of Rights
Almost every long-term disability claim in Philadelphia falls into one of two categories, and they are governed by entirely different bodies of law.
If you obtained the coverage through a private employer, your claim is likely governed by the Employee Retirement Income Security Act of 1974, a federal statute known as ERISA. Suits to recover benefits are brought under ERISA section 502(a)(1)(B), 29 U.S.C. § 1132(a)(1)(B).
Federal law displaces state law claims that relate to an employee benefit plan, which means that on a group claim there is no jury trial, no punitive damages, and no state law bad faith claim available. What the statute does provide is recovery of the benefits owed, with attorney’s fees and prejudgment interest available at the court’s decision.
If you bought the policy yourself, from an agent or through a professional association, ERISA usually does not apply. Your claim is a Pennsylvania insurance contract claim. That difference restores everything the federal statute removes: a jury, a claim for statutory bad faith, and the possibility of damages beyond the benefits themselves.
Government and church plans sit in a third category, since both are commonly exempt from ERISA, and a voluntary policy your employer merely allowed an insurer to sell you through payroll deduction may fall outside ERISA as well. None of these categories can be settled by guessing.
Consequently, working out whether your policy is governed by ERISA means reading the plan document, the certificate of coverage, and the summary plan description.
Does it matter whether my disability policy is governed by ERISA?
It matters more than any other fact about your claim. ERISA sets a federal appeal process with strict deadlines and generally removes jury trials, punitive damages, and state bad faith claims. A privately purchased policy goes by Pennsylvania contract and insurance law, which preserves those remedies.
The 24 Month Switch and the Denial That Arrives With It
Many group policies pay under an own occupation standard for the first 24 months and then change to an any-occupation standard. Claimants who have been paid without difficulty for two years may be caught entirely unprepared when a termination letter arrives on schedule, because nothing about their health has changed. But the contract changed, and that’s enough to cause trouble.
For instance, consider a tax accountant working in a Center City firm who develops a spinal condition that leaves her unable to sit for extended periods or maintain the hours her practice demands. For two years the insurer pays, because she cannot perform the material duties of her own occupation.
In month 25 the standard becomes whether she can perform any occupation for which her background qualifies her, and a vocational reviewer identifies sedentary roles that exist somewhere in the national economy. The letter that follows does not say she is healthy; it only asserts she is employable.
Answering that requires different evidence than the evidence that won the first two years. The question is no longer whether she can do her job, but whether the specific jobs the insurer identified are available to someone with her documented restrictions, whether those restrictions were accurately stated, and whether the vocational analysis accounted for the medication, the absenteeism, and the need to change position that her treating physicians describe.
All in all, a claim file built only to satisfy the own occupation standard will look thin the moment the standard changes. And the practical lesson is that the 24-month mark should be prepared early. It may sound obvious, but not all claimants take this into account, and it can have a negative and direct impact on a long-term disability claim.
Which Evidence Persuades a Reviewer
Insurers do not deny claims because they doubt a diagnosis. The may reason for which they deny claims is because the file does not connect the diagnosis to specific functional limitations, and does not connect those limitations to the specific duties of a specific job.
A note reading “patient is totally disabled” carries virtually no weight. On the contrary, a report describing that the patient cannot sit longer than 20 minutes without changing position, cannot lift more than 10 pounds occasionally, is limited to two hours of sustained concentration, and misses several workdays a month because of symptom flares, carries considerable weight, since each of those statements can be measured against a job description.
The evidence that tends to move a disability file includes treating physician statements written in terms of function rather than diagnosis, objective testing where the condition permits it, a documented and consistent treatment history, and a record of the accommodations already tried and failed at work.
Statements from supervisors and colleagues about observed decline can matter. So can a symptom diary kept contemporaneously rather than reconstructed after the denial.
The vocational half of the record is the half most often left thin. A disability file that establishes restrictions without establishing what the job actually required leaves the reviewer free to describe the occupation in whatever terms make it look manageable.
The employer’s written job description, the hours the role demanded, the travel, the standing, and the cognitive load all belong in the record, because the comparison a reviewer makes is between documented limits and a described job.
Where a condition resists objective imaging, as fibromyalgia and chronic fatigue syndrome do, the file has to be even more thorough. Functional capacity testing, neuropsychological testing, and detailed longitudinal treatment notes are some of the tools that can carry those claims.
The Appeal Is the Case
On an ERISA governed claim, the internal appeal is not a formality preceding the real fight. It is very often the entire fight, because the record closes at the end of it.
The federal claims procedure regulation at 29 C.F.R. § 2560.503-1 requires that a claimant be given at least 180 days after an adverse benefit determination to appeal. The insurer must decide an initial disability claim within 45 days, with two possible 30 day extensions, and must decide an appeal within 45 days, with one extension available.
You are entitled to receive the documents relevant to your claim on request and without charge, and to know the specific reasons for the denial, as the Department of Labor’s guidance on group disability claims procedure explains.
Where the plan gives the administrator discretionary authority to interpret the plan and decide benefit questions, a court reviews the denial deferentially, asking whether the decision was arbitrary and capricious rather than deciding the question fresh. And where the plan grants no such discretion, review is anew. Either way, the court is usually reviewing the administrative record that existed when the final decision was made.
That means evidence gathered after the appeal is decided may never be revised by the judge. The medical report obtained a month too late, the vocational analysis commissioned after suit is filed, the specialist consultation arranged once a lawyer is retained: all of it can arrive after the door has closed. Thus, building the record during the appeal window is the only opportunity most claimants get.
Three Different Clocks
Disability claimants routinely assume there is one deadline. In reality, there are at least three, and they run separately.
The first is the “internal” appeal deadline, 180 days from an adverse benefit determination on an ERISA governed claim. Missing it can end the claim outright, because courts generally require the plan’s internal process to be exhausted before a lawsuit may be filed.
The second is the deadline to file suit. ERISA section 502(a)(1)(B) contains no federal limitations period, so courts borrow the most closely analogous state period, which in Pennsylvania is the four year contract period under 42 Pa.C.S. § 5525.
However, that fallback is regularly overridden. Plans and policies commonly contain their own suit limitation clause setting a shorter window, and courts enforce a contractual limitation period where it is reasonable. The number that governs your claim is the one in your policy, and it may be considerably shorter than four years.
The third applies only where the policy is not governed by ERISA. A Pennsylvania breach of insurance contract claim carries the four year period under 42 Pa.C.S. § 5525, while a statutory bad faith claim under 42 Pa.C.S. § 8371 carries a two year period under 42 Pa.C.S. § 5524, treated as a statutorily created tort in Ash v. Continental Insurance Co., 932 A.2d 877 (Pa. 2007).
The same denial letter can therefore start two different clocks that expire two years apart.
How long do I have to appeal a denied long term disability claim?
On an ERISA governed plan you must be given at least 180 days from an adverse benefit determination to file an internal appeal. The deadline to file suit afterward is separate and is usually set by the policy itself, so you should check your own specific policy.
What Is at Stake When Benefits Stop
The value of a long-term disability claim is rarely the single missed payment that prompts the call. It is the stream of payments running to the policy’s end date, which for a claimant disabled at a young age can be decades of coverage, and it is the collateral consequences that arrive alongside the termination.
Three components make up most disability recoveries. The first is past due benefits, which is comprised of the months already missed between the termination and the resolution. The second is reinstatement going forward, which is the part claimants undervalue most and which is usually worth many times the arrears. The third, on an ERISA claim, is the discretionary award of attorney’s fees and prejudgment interest that a court may make under 29 U.S.C. § 1132(g).
Working against those figures are the offsets. Most group policies reduce the monthly benefit by other income the claimant receives, and a Social Security disability award is the most common, which makes how long term disability and Social Security disability interact a live question well before any award arrives.
Social Security awards are frequently retroactive, so an approval can produce a lump sum for a period during which the insurer was already paying, and the insurer will then demand repayment of the overlap. That overpayment demand is a predictable event, and it is more manageable when it is anticipated before the Social Security award arrives.
A lump sum buyout is a separate question that some insurers raise once a claim is stable. An offer to close the file permanently in exchange for a discounted present value can be reasonable or can be well below what the remaining benefit stream is worth, and the difference turns on the claimant’s age, the policy’s end date, the definition that will apply at the next review, and the strength of the medical record. None of that can be assessed from the offer letter alone.
Why You Do Not Sue Your Employer
Claimants may assume the employer is the opponent, since the employer chose the plan and the human resources department delivered the bad news. In a regular benefits dispute the employer is not the party that decided your claim and is not the party that owes you money.
The proper defendants are usually the plan itself and the insurance company that made the benefit determination. The insurer both funds the benefit and decides whether it is owed, a structural conflict that courts recognize and weigh when reviewing a denial. That conflict is a factor in the analysis, not an automatic ground for reversal, and it has to be shown in the record rather than asserted.
There are situations, however, where an employer’s conduct becomes relevant, including a failure to enroll an employee properly, misstatements about coverage, or termination of coverage before a claim was filed. Those are separate problems requiring separate analysis, and they do not change who decides the benefit question.
Where a Philadelphia Disability Case Is Heard
For a Philadelphia claimant with an employer sponsored plan, an ERISA suit for benefits is filed in the United States District Court for the Eastern District of Pennsylvania, which sits at the James A. Byrne United States Courthouse at 601 Market Street in Center City.
ERISA’s venue provision, 29 U.S.C. § 1132(e)(2), permits suit where the plan is administered, where the breach took place, or where a defendant resides or may be found, which is why a claimant living in Philly can litigate here even when the insurer is based elsewhere. Appeals from that court are heard by the United States Court of Appeals for the Third Circuit, which sits in the same building.
A claim on a privately purchased policy follows a different route. Breach of contract and statutory bad faith claims under 42 Pa.C.S. § 8371 are filed in the Court of Common Pleas of Philadelphia County, where a jury may hear the case and where the bad faith statute permits an award of interest on the claim at prime rate plus 3 percent, punitive damages, and court costs and attorney’s fees.
The burden on that bad faith claim is heavier than the ordinary civil standard. Under Rancosky v. Washington National Insurance Co., 170 A.3d 364 (Pa. 2017), which adopted the two-prong test from Terletsky, an insured must show by clear and convincing evidence both that the insurer had no reasonable basis for denying the benefit and that the insurer knew of or recklessly disregarded that lack of a reasonable basis.
Proof of a self interested or ill willed motive is not a required third element, though it works as evidence for that purpose.
Comparison: Group Plan Versus Individual Policy
It is clear that the two main policy kinds feature distinctive elements that need to be clearly differentiated in order for each kind of claim to move forward.
Still, all these differences regarding deadlines, appeals, and benefits can be confusing. Here is a quick summary of the main differences between ERISA and Pennsylvania insurance contract claims:
| Question | Employer sponsored group plan | Individually purchased policy |
| Governing law | Federal ERISA | Pennsylvania contract and insurance law |
| Internal appeal | Required, at least 180 days | Governed by the policy terms |
| Where suit is filed | Federal court, commonly E.D. Pa. | Court of Common Pleas of Philadelphia County |
| Jury trial | Generally unavailable | Available |
| Bad faith claim | Preempted | Available under 42 Pa.C.S. § 8371 |
| Recoverable | Benefits owed, with fees and interest at the court’s discretion | Benefits, plus bad faith remedies where proven |
Frequently Asked Questions
Can my insurer stop paying benefits it has already approved?
Yes. Insurers conduct periodic reviews and can terminate benefits they previously paid, most commonly when a policy’s definition of disability changes at 24 months.
Does receiving Social Security disability reduce my long term disability payment?
Usually yes. Most group policies contain an offset provision allowing the insurer to reduce the monthly benefit by the Social Security award, and an overpayment demand may follow a retroactive award.
Do I need to be bedridden to qualify for long-term disability benefits?
No. The question under most policies is whether you can perform the duties of your occupation, not whether you are incapacitated in every area of life.
What happens if I miss the 180 day appeal deadline?
Missing the internal appeal deadline can end your claim, because courts generally require the plan’s internal process to be exhausted before suit is filed. If you suspect a deadline may have passed, you should speak with a lawyer immediately.
Can I file a lawsuit without appealing first?
On an ERISA governed plan, generally no. The plan’s internal claim and appeal process must be exhausted before a court will hear the case.
How Edelstein Martin & Nelson, LLP Handles Long Term Disability Claims in Philadelphia
Our lawyers at Edelstein Martin & Nelson, LLP advocate for claimants in disability claims across Philadelphia and Pennsylvania. Our work begins with the documents first, then the diagnosis: we read the policy or plan to establish which body of law governs, identify the definition of disability that applies and when it changes, and find the limitation provisions that will shape the dispute.
From there, we aim to make the most of the appeal window, since that’s the time when evidence can still be added. Our team works hard to strengthen your claim with all available records.
One of our partners, Keith L. Martin, is specialized on private and group disability policy claims and insurance bad faith matters, so he handles long-term disability insurance claims for those claimants whose benefits have been denied or terminated.
We are prepared to deal with any hindrance that may appear during the course of your claim. Even when an insurer has simply stalled, our lawyers know how to handle delayed disability benefits.
Your initial consultation is free. Moreover, we get paid on a contingency basis, so there is no fee unless you are awarded your long-term disability benefit.
We invite you to bring the denial letter and the policy or plan document, and you will be told which regime governs your claim and what deadline is already running before you decide anything. You can contact our Philadelphia office to arrange your free initial case review.