When Your Disability Benefits Get Denied: Why You Need Legal Help
A long term disability attorney helps people fight insurance companies when their LTD benefits are wrongfully denied or terminated. Here’s what they do:
Key Services:
- Challenge denied disability claims
- Steer complex ERISA laws
- Gather medical evidence
- Negotiate with insurance companies
- File federal lawsuits when needed
- Work on contingency (no win, no fee)
When to Hire One:
- Your LTD claim was denied
- Benefits were suddenly cut off
- Insurance company demands unnecessary medical exams
- You’re facing policy definition disputes
- Appeal deadlines are approaching
When an injury or illness prevents you from working, the financial strain can be overwhelming. You have long-term disability (LTD) insurance for this exact reason, but getting benefits isn’t always easy. Insurance companies deny approximately half of all initial LTD claims.
LTD insurance is supposed to replace 60-70% of your income for an extended period, sometimes until retirement. However, insurers profit by collecting premiums and denying claims. They employ adjusters and lawyers to find reasons to say no.
This is where a long-term disability attorney becomes essential. They understand the complex insurance laws, medical requirements, and legal deadlines that determine the outcome of your case.
Understanding Your Eligibility and the Importance of Medical Evidence
Understanding your insurance policy’s definition of “disability” is critical. Most policies use two definitions that can dramatically affect your benefits.
Initially, you may be covered under an “own occupation” definition, meaning you cannot perform the duties of your specific job. After a set period, often 24 months, this typically shifts to “any occupation” disability. Now, you must prove you can’t perform any job for which you are reasonably qualified. This shift is a common point for claim denials, as insurers argue you could work in a different, lower-paying role.
Your policy documents contain the exact definitions and limitations that govern your case. We advise our clients in Orange County, Santa Ana, and Los Angeles to review them carefully. However, medical evidence is the cornerstone of your claim. Without solid documentation, your claim will likely be dismissed.
You need concrete proof, including detailed physician statements, ongoing treatment records, and test results. The documentation must clearly connect your medical condition to your inability to perform specific job duties. A long term disability attorney knows what evidence insurers require and how to present it effectively.
For more information on disability classifications, you can read about Benefits Partial Disability vs. Total Disability.
What Conditions Typically Qualify for LTD?
Many conditions can qualify for LTD benefits. Physical injuries and chronic conditions like severe back problems, spinal cord injuries, fibromyalgia, or chronic fatigue syndrome are common qualifiers. Heart disease and cancer can also be disabling, due to the conditions themselves or the side effects of treatment.
Autoimmune disorders such as lupus or multiple sclerosis often cause unpredictable flare-ups that make consistent work impossible. Mental health conditions like depression, anxiety, and PTSD are also valid reasons for long-term disability. You can learn more about how these cases are handled by exploring Mental Health Claims.
Newer conditions like Long COVID, mild traumatic brain injuries, and chronic headaches can also qualify if they significantly impact your ability to work. The key is not just the diagnosis, but proving how your symptoms prevent you from meeting job demands.
Why Insurance Companies Deny Claims and What to Do Next
Insurance companies are for-profit businesses, and they often fight to avoid paying benefits. Approximately half of all initial long-term disability claims are denied, so it’s wise to understand their tactics.
Common reasons for denial include:
- Insufficient medical evidence: Insurers may claim your records don’t prove your disability.
- Policy exclusions: Your policy might not cover pre-existing conditions or certain injuries.
- Missed deadlines: Strict timelines for filing claims and appeals can instantly kill a case.
- Insurer surveillance: Some companies hire investigators to find evidence contradicting your claim.
- The “any occupation” trap: After 24 months, insurers may argue you can perform some other job.
How insurers assess claims
First, a claims adjuster, who may lack medical training, reviews your file. Then, you may be sent for an Independent Medical Exam (IME) with a doctor chosen and paid by the insurer, who often sides with the company. Finally, a vocational assessment may be used to argue that other jobs are available to you. This process is stressful and can worsen your health.
First Steps to Take After a Denial
Receiving a denial letter is disheartening, but it’s not the end. Take these immediate steps:
- Read the denial letter carefully to understand the exact reasons for the denial.
- Mark all appeal deadlines on your calendar. You typically have 180 days, but it can be less.
- Gather your complete policy documents, including all amendments.
- Consult a long term disability attorney before filing an internal appeal. These appeals are rarely successful and can be a delay tactic by the insurer.
The appeal process has similarities to other legal areas. For instance, you can learn more about Appealing Denied Workers Compensation Claims. Insurance companies count on you giving up. Don’t.
How a Long Term Disability Attorney Can Secure Your Benefits
Facing an insurance company alone is a daunting task. They have teams of lawyers and investigators; you’re dealing with a health crisis. This is when you need a long term disability attorney.
At Adam Krolikowski Law Firm, we have over 25 years of experience with complex cases in Orange County, Santa Ana, and Los Angeles. Insurance law, especially ERISA (Employee Retirement Income Security Act), is filled with traps. We handle these complexities for you.
- Evidence Gathering: We work with your doctors to get the detailed reports insurers require, explaining why you can’t work.
- Insurer Communication: We manage all contact with the insurance company, protecting you from their tactics.
- Settlement Negotiation: We analyze any buyout offers to ensure they are fair. Our approach is similar to our work in Personal Injury Attorneys Negotiations—we fight for what you deserve.
- Litigation: If negotiations fail, we are prepared to take your case to federal court, presenting a compelling argument to a judge.
Potential outcomes include reinstatement of benefits with back pay or a lump-sum buyout. When we win in court, insurers may also have to pay attorney fees.
What to Expect When Working with a Long Term Disability Attorney
We aim to reduce your stress. During a free initial consultation, we’ll review your denial letter and discuss your situation. We conduct a thorough document review of your policy and medical records. We then develop a case strategy with you, explaining your options and timelines. You can expect regular communication and strong advocacy throughout the process.
How Lawyers Charge for LTD Cases
We work on a contingency fee basis. This means you pay us only if we win your case, with our fee being a percentage of the benefits we recover. This is our No Win No Fee promise.
We also cover all upfront costs, such as filing fees and medical record requests. This approach ensures everyone can access quality legal help, regardless of their financial situation.
Complex Issues: Termination, SSDI, and Finding the Right Lawyer
Long-term disability cases often intersect with other legal areas, creating complex situations that require careful navigation.
Many clients ask, “Can my employer fire me while I’m on disability?” The answer is often yes. However, if you are terminated, your LTD benefits usually continue. If you believe the termination was because of your disability, it may be wrongful termination, which violates the law. Our team in Los Angeles handles these overlapping issues, as detailed in our Disability Discrimination Attorney Los Angeles resource.
People also confuse private disability insurance with Social Security Disability Insurance (SSDI). They are very different:
| Feature | Private Long-Term Disability Insurance | Social Security Disability Insurance (SSDI) |
|---|---|---|
| Source | Private insurance company through your employer or purchased individually | Federal government program funded by payroll taxes |
| Who Qualifies | Varies by policy – often “own occupation” initially, then “any occupation” | Extremely strict – unable to do any substantial work for at least 12 months |
| Benefit Amount | Usually 60-70% of your pre-disability income | Based on your lifetime earnings – typically much lower |
| Waiting Period | Often 90-180 days after short-term disability ends | Five full months after your disability begins |
| How Long Benefits Last | Until you recover, reach retirement age, or your policy ends | Until you recover or reach retirement age |
| Legal Process | Contract disputes with insurance companies, often under ERISA law | Administrative appeals through Social Security, then potentially federal court |
You can often receive both, though your private LTD benefits may be reduced by your SSDI award.
What to Gather Before Your Consultation
To help us understand your case quickly, please bring the following to your first meeting:
- Your complete denial letter.
- All insurance policy documents.
- Medical records related to your condition.
- All communications with your insurer (letters, emails, call notes).
- Your job description and recent pay stubs.
Finding a Reputable Long Term Disability Attorney
Choose an attorney with significant experience in ERISA claims, as this federal law governs most employer-sponsored plans. Look for positive client reviews and a proven process for handling complex cases. The fee structure should be contingency-based, with no upfront costs.
At Adam Krolikowski Law Firm, we have over 25 years of experience with these cases. We offer virtual consultations via ZOOM or TEAMS for clients in Orange County, Santa Ana, and Los Angeles, ensuring accessibility and clear communication.
Frequently Asked Questions about Long-Term Disability Claims
Here are answers to some of the most common questions we hear from clients in Orange County, Santa Ana, and Los Angeles.
How long will my disability case take?
The timeline varies. An administrative appeal can take several months, while a federal lawsuit may take a year or more. Case complexity and insurer cooperation are major factors. We provide realistic expectations for your specific situation and handle the legal work while you focus on your health.
Can I settle my long-term disability claim for a lump sum?
Yes, a lump-sum buyout is a common outcome. It provides financial certainty and ends your relationship with the insurance company. However, it also means no more monthly payments. A long term disability attorney is crucial for negotiating a fair settlement. We analyze the present value of your future benefits and advise you on whether an offer is in your best interest.
What’s the difference between LTD and Workers’ Compensation?
This is a frequent point of confusion. They cover different situations:
- Long-term disability (LTD) is for injuries or illnesses that are not work-related.
- Workers’ compensation is for injuries or illnesses that happen because of your job.
Sometimes, claims can overlap. For example, a work injury might worsen a pre-existing condition. It’s important to understand which system applies to you. You can learn more about your rights in our resources on Work Injury Claims Workers Comp Lawyer. Having legal guidance is key to navigating these systems and securing the full benefits you deserve.
Conclusion: Taking the Next Step to Protect Your Future
When a disabling condition disrupts your life, you shouldn’t have to fight an insurance company for the benefits you paid for. Claim denials, complex paperwork, and uncooperative adjusters can feel overwhelming, but you don’t have to face this battle alone.
The deck is stacked against you, but taking action is crucial. Deadlines are strict, and the sooner you get legal guidance, the better your chances of securing your financial future.
At Adam Krolikowski Law Firm, we have over 25 years of experience handling complex disability cases, often at the intersection of employment and personal injury law. We serve clients throughout Orange County, Santa Ana, and Los Angeles, working on a contingency fee basis—you pay nothing unless we win.
Whether you’re facing a denied claim or just starting the process, a long term disability attorney can make all the difference. We handle the legal fight so you can focus on your health.
For help with a disabling condition, including a serious Brain Injury Lawyer in Orange County CA, contact us for a free consultation. Let us fight for the benefits you deserve.