LTD benefits are intended to cover income when a medical condition causes one to be unable to work. In practice, most of these claims end up being a paperwork-based contest with the insurance company, who seek reasons to deny, delay, or even terminate benefits. Complaints and longer personal statements by claimants tend to be the least effective responses. It is a disciplined approach of the law, which foresees the reasons behind the insurers’ actions, and robust documentation that is most effective and can withstand examination at all levels.
The following are typical insurance company strategies in LTD cases, and the strategies long-term disability attorneys normally use to overcome them.
1) Reducing the Claim to a Trap of Medical Evidence
- The strategy: Insurers frequently refuse to approve or terminate claims on the grounds that there is a lack of objective evidence, particularly regarding conditions that may be hard to quantify using a single exam (chronic pain, migraines, fatigue-related disorders, and most mental disorders). They often also cite excessive subjectivity in treatment notes, inconsistency in records, or a lack of documented functional impairment to deny claims.
How lawyers respond:
- Base the record on function and not solely on diagnosis. A diagnosis alone is often insufficient to demonstrate disability. Lawyers assist in relaying how conditions impact the performance of occupational duties by outlining constraints, boundaries, unsuccessful job endeavors, symptoms, cognitive stamina, and impact on daily living.
- Provide targeted documentation by treating providers. Treating physicians are asked to identify limitations related to job requirements (sitting/standing tolerance, lifting limits, attention span, pain flares, medication side effects, and attendance reliability).
- Obtain supportive tests where necessary. Where the condition permits, lawyers may suggest functional testing, neuropsychological testing, or other testing that documents quantifiable limitations, then ensure that the findings are clarified in vocational terms.
- Supply explanations so that insurers don’t take advantage of loopholes. Insurers can cite late appointments, inconsistent treatment, or unclear chart notes as indicators of improvement. Lawyers work to present a consistent, well-documented medical history that accurately reflects the claimant’s condition and prevents such loopholes from being used against the claim.
2) Depending on Paper Reviews Rather Than on Real Examinations
- The strategy: Doctors who never see the claimant often review the claimant’s records under the pretense of providing an independent opinion on disability. Such reviewers can cherry-pick documentation, minimize symptoms, and make judgments that the claimant can work with, which later form the basis for a denial or termination.
How lawyers respond:
- Request a thorough review and rectify errors of fact. Lawyers review the reports for misquotes, missing exhibits, incorrect dates, and selective reading of the medical records.
- File rebuttals in a structured manner. A strong rebuttal does not just disagree. It identifies supportive medical entries, links them to functional limitations, and explains why the reviewer’s conclusions are medically or logically unsound.
- Bring in additional professional help where required. In some cases, lawyers will ask a claimant’s treating provider to rebut the conclusions of the insurer’s reviewer.
3) Manipulating Independent Medical Exams to Produce Doubt
- The strategy: Insurance companies might insist on an independent medical exam (IME). The exam can be short, contain little significant testing, and be worded to highlight ordinary observations while ignoring actual constraints.
How lawyers respond:
- Prepare the claimant for the exam. Lawyers describe the purpose of the exam, explain why questions can be phrased in a certain way, and advise on how to evade pitfalls.
- Make sure that there is consistency with the existing record. The idea is not dramatization. It is about accuracy and consistency, since inconsistency is a denial anchor commonly employed by insurers.
- Question defective IME reports. Lawyers counter the lack of supportive findings by comparing the IME’s claims with the longitudinal history of treatment, treating providers’ opinions, and objective medical evidence.
4) Social Media Monitoring and Surveillance
- The strategy: Insurers can employ investigators or conduct web-based surveillance to record isolated instances and contend that such instances are evidence of work capacity. Even the most benign footage can be exaggerated to support their claims.
How lawyers respond:
- Put surveillance in context. A brief video clip rarely shows the full picture, such as symptom flare-ups, prolonged recovery periods, sudden pain, or the inability to sustain activity consistently over time.
- Enhance consistency of records. Lawyers underline the distinction emphasize the difference between occasional activity and the capacity to perform full-time work. Many long-term disability policies hinge on the ability to work reliably over an extended period, not on completing isolated tasks.
- Guard against social media missteps. Public posts can be misleading. Claimants are generally advised to limit content that might portray a rare “good day” as representative of typical functioning.
5) Switch Own Occupation to Any Occupation
- The strategy: There are numerous LTD policies where the definition of disability changes after a certain period (usually 24 months). During the initial stage of disability, insurers determine if a claimant can perform the duties of their regular occupation. When the definition of disability changes, insurers will argue that a claimant can do other work and is no longer disabled. Insurers review claims at this change in definition and often terminate benefits.
How lawyers respond:
- Make the insurer adopt the correct vocational assumptions. Any occupation is not any job in the universe. The occupations identified by the insurer must be based on the claimant’s training, education, experience, wages, and realistic job prospects in the area.
- Use vocational evidence strategically. Lawyers can also present vocational reports that examine job requirements, transferable skills, cognitive/physical requirements, and why the suggested jobs are not viable due to medical restrictions.
- Document ongoing disability proactively. Lawyers work to ensure that the file contains as much support of a continued disability as possible before an insurer denies ongoing benefits.
6) Functional Capacity Testing and Selective Utilization of Results
The strategy: Insurers may rely on a Functional Capacity Examination (FCE) to argue that a claimant can perform at a higher level than indicated by treating physicians, or to suggest submaximal effort. In some cases, isolated test results are emphasized to support a denial of benefits.
How lawyers respond:
- Assess the usefulness of an FCE or its detriment. When conducted and analyzed correctly, an FCE can meaningfully support a disability claim. However, where the testing does not account for the claimant’s specific medical condition—particularly conditions marked by fluctuation or delayed symptom exacerbation, its conclusions may be challenged.
7) The Paper Chase and Delay-By-Documentation
The strategy: Insurers can repeatedly demand records, forms, updates, and clarifications. They sometimes impose unrealistic deadlines that, if not met, they can later use as examples of non-compliance with the policy and a reason to suspend benefits or deny the claim.
How lawyers respond:
- Create a paper trail. Lawyers keep track of requests, submissions, confirmations, and follow-ups, so that insurers can’t claim that information was not submitted.
- Request the full claim. Lawyers can request the full claim file from the insurer for review to confirm that the requested information exists in the file and challenge assertions that medical evidence and documentation were not timely received by the insurer.
8) Winning the Appeal Stage Through the Creation of the “Administrative Record”
In the case of employer-sponsored LTD plans, claims are generally governed by the Employee Retirement Income Security Act (ERISA), a federal law that establishes uniform standards for employee benefit plans. Under ERISA, the administrative appeals process is critically important. ERISA regulations, as enforced by the U.S. Department of Labor, require that claimants be given at least 180 days from receipt of an adverse benefit determination to file an appeal. These deadlines are strictly applied, and failure to comply can bar further review.
How lawyers respond:
- Treat the appeal as the main show. In an ERISA-governed claim, the administrative appeal is often your only opportunity to submit critical evidence. Lawyers focus on developing the strongest evidence for the appeal, including specialist reports, diagnostic tests, vocational analysis, and detailed documentation of functional limitations.
- Demand a “full and fair review.” ERISA requires plan administrators to provide a meaningful appeal process, including a reasonable opportunity to respond to adverse findings. Lawyers review and rebut the unfavorable evidence generated on appeal.
- Control the narrative with organized, policy-driven evidence. A persuasive appeal aligns the medical and vocational evidence with the plan’s definition of disability, the claimant’s occupational duties, and the specific policy terms.
Final Thought
Insurance carriers handling long-term disability claims rarely act randomly. Instead, they often rely on recurring strategies, such as characterizing documented conditions as “subjective,” conducting surveillance, or progressively narrowing the policy’s definition of disability over time. Experienced long-term disability lawyers build a cohesive, well-documented evidentiary record. By integrating medical findings, functional capacity evidence, and vocational analysis into a consistent narrative, they create a record that is substantially more difficult for the insurer to refute.
