Insurance claims denied or underpaid
Your disability claim was denied: what to gather before the appeal deadline
The letter is on the kitchen table, and it says you aren't disabled enough. You have a deadline you don't fully understand and a stack of papers in three different places.
This guide is for a long-term disability claim through your job. It helps you get the papers into one place, in the order that matters, so whoever helps you with the appeal can start on the substance instead of the search.
First, find your deadline and write it down
The denial letter must tell you how to appeal and the time limit for doing it. That time is counted from the day you receive the letter, so write that day on the letter itself and keep the envelope. If the letter is unclear about the deadline, ask the insurer in writing to confirm it, and keep a copy of what you sent.
Gathering papers must never push you past the deadline. If it is close, speak with a lawyer licensed where you live or worked now, with whatever you have.
Ask the insurer for everything it used
The claim file is every document, record and note the insurer relied on, considered or created while deciding your claim, including reports from doctors and job experts it hired. For coverage through work, you can ask for a copy free of charge. Ask in writing, in a way that lets you prove when you sent it, and note the date. You can't answer the insurer's reasons well without seeing what it relied on.
Get the policy and the plan papers
Find the policy or certificate of coverage, and any plan papers your employer gave you, including the summary plan description (the plain-language booklet that explains the plan and how to make a claim). If you don't have them, ask your employer's benefits or human resources office in writing. Look for the page that defines disability, and note whether the definition changes after a period of time.
Gather your medical records, and ask your doctors the right question
List every doctor, clinic, therapist and hospital that has treated you for the conditions that stopped you working, with rough dates, and ask each for your records. Keep test results, imaging reports and a current list of medications and their side effects.
The denial letter must explain why the insurer disagreed with your own doctors. Show your doctors that explanation. A letter that answers it, describing what you can and can't do (how long you can sit, stand or concentrate, and how often you would miss work), often helps more than a diagnosis alone.
Collect every letter, form and call
Keep every letter, email and portal message to and from the insurer, the forms you filled in, and any report from the insurer's own doctors or job experts. Add notes of phone calls: the date, who you spoke to and what they said. If the insurer mentions surveillance or your social media, keep that letter too.
Put the dates in order
Write a short, dated timeline: your last day at work, when you were diagnosed, the main points in your treatment, when you filed the claim, when benefits started and stopped, when each letter arrived, and any Social Security disability application or decision. Rough dates are fine. The timeline is often what shows that a denial doesn't fit the facts.
What to be careful with
Keep seeing your doctors, and describe your limits to them honestly and consistently. Assume the insurer may read what you post online. Don't send the insurer a short note that only says you disagree: the person deciding the appeal must consider everything you send, and in many cases what is in the file when the appeal closes is all a court will later see.
Nobody can promise how an appeal ends. The insurer decides it, and if the claim goes further, a court decides. Good preparation gives your claim the fullest hearing it can have.
Your short list
- The denial letter, with the day it arrived written on it, and the envelope.
- Your appeal deadline as the letter states it.
- A written request for the claim file, with the date you sent it.
- The policy or certificate, and the summary plan description.
- A list of every treating doctor, with dates, and the records you have.
- A letter from your doctor about what you can and can't do.
- Every letter, form and call note, in date order.
- A dated timeline, from your last day at work to today.
This page explains things in general terms. It is not legal advice about your situation, and the law differs from state to state.