The car accident left you with a traumatic brain injury that affects your memory, concentration, and ability to perform your job. Or perhaps chronic pain from spinal injuries makes it impossible to sit at a desk for eight hours. You filed a long-term disability (LTD) claim with your employer’s insurance, confident your documented medical conditions would result in approval.
Instead, you received a denial letter filled with medical jargon claiming you don’t meet the policy’s definition of “disability,” that your condition isn’t severe enough, or that you could perform “sedentary work.” You’re devastated. Without income and facing mounting bills, you don’t know how you’ll support your family.
You wonder: Can I appeal this denial? Do I need an attorney? What are my rights?
Long-term disability insurance is supposed to provide financial protection when serious injuries or illnesses prevent you from working. Unfortunately, insurance companies deny legitimate claims at alarming rates, hoping claimants will give up or accept inadequate settlements. Fighting LTD denials requires understanding complex ERISA regulations, policy definitions of disability, appeals procedures, and litigation strategies.
Whether your disability stems from an accident, illness, or chronic condition, having an experienced disability attorney dramatically improves your chances of securing the benefits you’ve paid for and deserve.
Understanding Long-Term Disability Insurance in Michigan
Long-term disability insurance provides income replacement when injuries or illnesses prevent you from working for extended periods:
Types of LTD Coverage:
Employer-Sponsored Group Plans: Most LTD coverage comes through employer benefit plans, typically:
- Paying 50-70% of pre-disability income
- Requiring elimination periods (90-180 days of disability before benefits begin)
- Governed by federal ERISA law
- Having specific definitions of “disability”
Individual LTD Policies: Some professionals purchase private LTD policies offering:
- Higher benefit percentages
- Better definitions of disability
- Longer benefit periods
- Not subject to ERISA (more claimant-friendly)
**”Own Occupation” vs. “
Own Occupation: You’re disabled if you can’t perform your specific job duties. This favorable definition protects professionals whose specialized skills are compromised.
Any Occupation: You’re disabled only if you can’t perform ANY occupation for which you’re reasonably suited by education, training, and experience. Much harder to prove.
Hybrid Definitions: Many policies use “own occupation” for initial periods (2 years), then switch to “any occupation” thereafter, creating denial triggers when definitions change.
Why Claims Are Denied:
Understanding why insurance companies deny legitimate claims reveals the profit-driven motives behind many rejections. Disability insurance is profitable when companies collect premiums but deny claims, which is why they employ staff whose primary job is finding reasons to deny rather than approve. Conditions with subjective symptoms like pain, fatigue, and cognitive issues face more scrutiny than objective injuries that show up clearly on medical imaging.
Companies routinely hire private investigators to conduct surveillance, hoping to video claimants performing activities that appear to contradict disability claims, even when brief activities on good days don’t reflect sustained work capacity.
Insurance companies also send claimants to Independent Medical Examinations (IMEs) conducted by doctors who regularly work for insurance companies and who frequently find claimants “not disabled,” regardless of overwhelming contrary evidence from treating physicians. Additionally, companies hire vocational experts who claim you can perform sedentary or light-duty jobs that don’t actually exist in realistic job markets, even when your own doctors disagree with these assessments.
At The Joseph Dedvukaj Firm, while we primarily focus on personal injury cases, we understand how accident-related disabilities affect long-term earning capacity and work with clients and specialized disability attorneys to address these issues comprehensively.
ERISA Regulations and How They Affect Disability Claims
Most employer-sponsored LTD plans are governed by the Employee Retirement Income Security Act (ERISA), a federal law creating unique procedures and limitations:
ERISA Advantages (for insurers):
ERISA creates a litigation landscape heavily tilted toward insurance companies. Unlike typical lawsuits, ERISA cases have severely limited discovery. You cannot depose insurance company employees, obtain internal documents revealing bad faith practices, or fully investigate the claim handling process that led to your denial.
Courts generally only consider evidence submitted during the administrative appeals process, making new evidence at trial highly restricted and emphasizing the critical importance of building a complete record during appeals.
ERISA cases are decided by judges rather than juries, eliminating the emotional appeals and sympathy factors that might otherwise influence decision-makers evaluating your suffering and disability. Even when insurers act in egregious bad faith, punitive damages aren’t available under ERISA. Claimants can only recover withheld benefits and attorney fees, removing the financial deterrent that might otherwise discourage wrongful denials.
Adding insult to injury, courts often give “deference” to insurers’ decisions, making it significantly harder to overturn denials even when the evidence overwhelmingly supports disability.
ERISA Procedures:
Initial Claim: File comprehensive LTD claim with medical documentation, physician statements, and functional capacity information.
Denial: If denied, insurers must provide written explanation citing policy provisions and reasons.
Administrative Appeal: You have 180 days to appeal denials, submitting additional evidence and arguments. This is crucial because the administrative record is often the only evidence considered in court.
Final Decision: Insurers must issue final decisions on appeals.
Federal Lawsuit: If appeals are denied, you can file ERISA lawsuits in federal court.
Critical Strategy:
The administrative appeal stage is most important: building a strong administrative record with comprehensive medical evidence, expert opinions, and persuasive arguments. Poor appeals doom ERISA lawsuits.
Common Reasons for LTD Claim Denials
Understanding why insurers deny claims helps you build stronger cases:
“Doesn’t Meet Definition of Disability”:
The most common denial reason involves insurers claiming you can still perform your job or “any occupation” suitable for your education and experience. Successfully countering this requires building comprehensive evidence through multiple sources. You need detailed physician opinions explicitly explaining your functional limitations and why they prevent work, functional capacity evaluations conducted by qualified professionals documenting your specific physical and cognitive restrictions, vocational expert testimony establishing that no suitable jobs actually exist in realistic job markets given your particular restrictions, and job description documentation showing your specific occupation’s physical and cognitive requirements that you can no longer meet.
“Lack of Objective Medical Evidence”:
For subjective conditions (pain, fatigue, cognitive issues), insurers demand “objective” proof.
- MRI, CT, EMG, or other diagnostic imaging
- Neuropsychological testing for cognitive issues
- Consistent treatment records over time
- Specialist evaluations (neurologists, pain management, psychiatrists)
“Treatment Not Consistent with Disability”:
Insurers argue if you’re not aggressively treating, you can’t be truly disabled.
- Following all treatment recommendations
- Attending all appointments
- Documenting why certain treatments weren’t pursued (side effects, contraindications, ineffectiveness)
“Surveillance Contradicts Claims”:
Video showing you performing activities (bending to pick up mail, grocery shopping) is used to claim you’re not disabled.
- Being truthful about capabilities
- Understanding brief activities on good days don’t mean you can work full-time
- Having doctors explain how episodic functioning differs from sustained work capacity
“Independent Medical Examination Findings”:
Company-hired doctors often find claimants not disabled.
- Treating physician opinions (more credible than one-time exams)
- Pointing out IME doctors’ bias and financial relationships with insurers
- Demonstrating IME doctors’ incomplete reviews
“Pre-Existing Condition Exclusions”:
Policies may exclude coverage for conditions existing before coverage.
- Showing current disability stems from new events (accidents)
- Proving significant worsening of pre-existing conditions
- Demonstrating you were actively working before claim
Proving Disability After Accidents and Injuries
Accident-related disabilities present unique challenges in LTD claims:
Traumatic Brain Injuries:
TBI often causes cognitive deficits that insurers dismiss because victims look healthy:
Proving TBI Disability:
- Neuropsychological testing documenting cognitive impairments
- Neurologist opinions explaining how deficits prevent work
- Employer statements about performance decline
- Family testimony about personality changes and functional limitations
Chronic Pain Conditions:
Pain from accident injuries (back pain, neck pain, nerve damage) faces scrutiny because pain is subjective:
Proving Pain Disability:
- MRI/CT showing structural damage
- Pain management specialist treatment records
- Medication histories showing ongoing analgesic needs
- Functional capacity evaluations documenting limitations
- Day-in-the-life documentation showing activity restrictions
Orthopedic Injuries:
Fractures, joint injuries, and soft tissue damage:
Proving Orthopedic Disability:
- Imaging showing structural damage
- Orthopedic surgeon opinions on permanent restrictions
- Range-of-motion testing
- Lifting, sitting, standing capacity evaluations
- Job demands analysis showing incompatibility with restrictions
Psychological Conditions:
PTSD, anxiety, depression from accidents:
Proving Psychological Disability:
- Psychiatrist/psychologist diagnoses
- Psychological testing
- Medication management records
- Therapy notes documenting symptoms and functional impacts
- Statements about concentration, interpersonal function, stress tolerance
Combining Multiple Impairments:
Often, no single condition is disabling, but combined effects are.
- Comprehensive picture of how multiple conditions interact
- Cumulative functional limitations
- How combined effects prevent work even if individual conditions might not
Appealing LTD Denials and Maximizing Recovery
Successfully appealing LTD denials requires strategic action:
Immediate Steps After Denial:
Review Denial Letter: Identify specific reasons cited and policy provisions referenced.
Obtain Complete File: Request your entire claim file from the insurer to understand what evidence they considered and what’s missing.
Consult Attorneys: LTD appeals benefit enormously from experienced legal representation. Don’t go it alone.
Meet Deadlines: Missing the 180-day ERISA appeal deadline destroys your claim. Act quickly.
Building Strong Appeals:
Comprehensive Medical Evidence:
- Updated physician opinions addressing denial reasons
- New diagnostic testing
- Specialist evaluations
- Functional capacity evaluations
Vocational Analysis:
- Independent vocational expert opinions
- Labor market surveys showing no suitable jobs
- Analysis of transferable skills and restrictions
Legal Arguments:
- Point out insurers’ errors in applying policy terms
- Cite case law supporting your position
- Demonstrate violations of claims handling standards
Personal Statement:
- Detailed explanation of daily life limitations
- Specific examples of failed work attempts or why return is impossible
- Impact on quality of life
Third-Party Statements:
- Family testimony about observed limitations
- Former employer statements about performance decline
- Witness accounts of your condition
If Administrative Appeals Fail:
ERISA Lawsuit: File in federal court within statute of limitations (varies by circuit, typically 3 years from final denial).
Standard of Review: Courts apply either “de novo” (fresh review) or “abuse of discretion” (deferential) standards depending on policy language.
Remedy: If successful, you recover past-due benefits plus attorney fees. Future benefits may be awarded or remanded to insurer for reconsideration.
Get Help from Experienced Michigan Personal Injury Lawyers
Long-term disability denials devastate families already facing medical challenges and financial strain. While The Joseph Dedvukaj Firm primarily handles personal injury cases, we understand how accident-related disabilities affect long-term earning capacity and quality of life.
For accident-related injuries causing long-term disability:
Our Role: We ensure personal injury settlements account for diminished earning capacity and future losses. If your accident injuries affect your ability to work, we calculate these losses in your personal injury claim.
Disability Specialists: For LTD claim appeals and ERISA litigation, we refer clients to experienced disability attorneys who specialize in these complex cases.
Comprehensive Approach: The best outcomes occur when personal injury claims and disability claims are coordinated strategically, ensuring maximum total recovery.
The Joseph Dedvukaj Firm has recovered over $300 million for injured Michigan residents, including substantial compensation for victims whose injuries caused permanent work disabilities.
Attorney Joseph Dedvukaj’s AV Preeminent rating and National Trial Lawyers: Top 100 membership demonstrate exceptional legal skill.
If you’ve been injured in an accident and face long-term disability, contact us for a free consultation to discuss your personal injury claim and how it intersects with disability benefits. Call 1-866-HIRE-JOE or visit our website. We serve clients throughout Michigan from our Bloomfield Hills office.
We work on a contingency fee basis for personal injury cases. Don’t let accident-related disabilities rob you of both health and financial security. Let experienced attorneys fight for all available compensation while you focus on medical treatment and adaptation.
Learn more about our social security disability practice and personal injury experience on our website.