You applied for long-term disability benefits through your employer’s insurance plan. You thought you had enough medical proof.
Then, you got the letter.
The insurance company denied your claim. Now you’re wondering what to do next—and how many chances you have to get this right.
Let’s talk about how many times you can appeal an ERISA long-term disability denial—and how to protect yourself.
How Many Times Can You Appeal a Disability Claim? Insights on Most ERISA Plans
The majority of long-term disability plans governed by ERISA allow just one administrative appeal of the original decision.
That’s it.
This means you have one opportunity to appeal a decision—this is the first and only level of appeal in most ERISA plans—submit evidence, respond to the denial, and build your case.
After that, the next step is filing a lawsuit in federal court. But here’s the catch:
In court, you can’t submit new evidence. The judge only reviews what you submitted during your appeal.
That’s why the appeal is the most important stage of your case. You must make it count.
Introduction to ERISA and Disability Benefits
The Employee Retirement Income Security Act (ERISA) is a federal law that regulates employee benefit plans, including disability benefits. If you receive disability benefits through an employer-sponsored plan, ERISA likely governs your case. Understanding ERISA and its implications is crucial when navigating the disability benefits system.
ERISA sets the standards for how disability benefits are managed and what rights you have if your claim is denied. It outlines the appeals process you must follow and limits the evidence you can present in court. This makes the appeal stage incredibly important, as it builds the entire record that a federal judge will review if you need to file a lawsuit.
The Social Security Administration (SSA) also plays a role in determining disability benefits, particularly for Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI).
When applying for social security disability benefits, the process begins with the initial application. Many disability applications are denied at first, resulting in a social security disability denial.
After a denial, you can file a reconsideration or reconsideration appeal, which is reviewed by Disability Determination Services (DDS).
If your claim is denied again, you may request a disability hearing at the hearing level, where an administrative law judge (ALJ) conducts an administrative law judge hearing to review your case. If the ALJ denies your claim, you can seek an appeals council review by the Appeals Council, which is the next step before possibly filing a new claim or pursuing federal court.
While ERISA governs employer-sponsored plans, the SSA oversees federal disability benefits. Understanding the interplay between these entities can help you better navigate the appeals process and improve your chances of securing the benefits you deserve.
Some Policies Allow Two Appeals—But It’s Not Guaranteed
A small number of insurance plans allow two levels of appeal, each representing a different appeal level. In most cases, however, policies do not allow more than one appeal.
In some policies, the second appeal is mandatory. In others, it’s voluntary or discretionary.
The denial letter should tell you how many appeals you have. But sometimes, the letter is vague or confusing.
Don’t guess.
Call the insurance company and ask. Get it in writing. Check the policy itself.
If you only get one appeal, you need to hire a lawyer now. Not later. Not after you try it on your own.
Once that deadline passes, you may have no legal recourse.
Why the Appeal Stage Is So Critical
Under ERISA, the administrative appeal builds your entire court record.
In some cases, this may involve preparing for an appeal hearing, which is a crucial opportunity to present your case.
That means:
- No testimony
- No cross-examining doctors
- No new documents
- No second chance
If you submit a weak or incomplete appeal, you’ve likely destroyed your chances in court.
You must put all relevant evidence into the file before the appeal deadline. If you don’t, a federal judge can’t consider it.
Insurance companies know this. They count on you not knowing the rules.
They hope you’ll treat the appeal like a formality. But it’s your best—and often only—shot at reversing a denial.
What to Include in Your ERISA Appeal
Your appeal must directly respond to every reason for denial listed in the letter, ensuring that the claims examiner has all the necessary information to review your case.
It’s not enough to send in a few doctor’s notes. You need to build a comprehensive, well-documented case.
Here’s what your appeal should include:
✅ Complete Medical Records
Don’t rely on the insurance company to gather your records. Send in everything:
- Office notes
- Test results
- Imaging
- Surgical reports
- Mental health evaluations
If you’re missing records, request them immediately. Time is limited. Accurate and complete medical records can also impact the amount of back pay you may be eligible to receive.
✅ Detailed Doctor Letters
Ask your doctors to write narrative letters. These letters should explain:
- Your diagnosis
- Your symptoms
- Your limitations
- Criteria for long-term disability
- Why you can’t work in your own occupation—or any occupation
Make sure your doctors understand the definition of disability under your policy. That definition matters more than their general opinion. These letters help the claims examiner determine whether you meet the medical requirements for disability benefits.
✅ A Personal Statement
Write a letter explaining how your condition affects your daily life. Be specific.
Describe what you can’t do anymore. Explain how your symptoms have impacted your work and routines. Remember, a new person will review your appeal, and your personal statement can provide valuable context.
This statement should be a sworn statement in the form of an affidavit and signed by a notary public. That adds much credibility to the document especially when you get to federal court.
✅ Vocational Evidence
If possible, include a vocational assessment. This expert opinion helps show how your medical condition prevents you from working.
Don’t assume the insurer will figure this out on its own. You have to connect the dots.
A strong vocational assessment can significantly increase your chances of receiving a favorable decision.
Can You Appeal Without a Lawyer?
Technically, yes. But that doesn’t mean you should.
Every document you submit must be filed correctly and on time to avoid jeopardizing your appeal.
You wouldn’t try to perform surgery on yourself. Don’t try to handle a complex legal and medical appeal alone either.
Here’s why:
ERISA law is designed to favor insurance companies.
Your appeal must meet legal and medical standards. You must interpret your policy language. You must also understand what kind of evidence is persuasive.
One missed deadline. One vague doctor letter. One unsupported statement. That’s all it takes to lose.
An experienced ERISA attorney knows how to build the kind of appeal that holds up in federal court—if it comes to that.
Navigating the System and Seeking Help
Navigating the disability benefits system can be complex and overwhelming, especially when dealing with a denial of benefits. If your initial claim is denied, you have the right to appeal the decision.
Seeking help from a qualified attorney or representative can significantly improve your chances of winning your disability case. They can guide you through the appeals process, help you gather additional medical evidence, and represent you in the appeal and in federal court. An experienced representative understands the nuances of the system and can help you build a strong case.
Key points to remember:
- You have the right to appeal a denial of benefits.
- Additional medical evidence can be crucial in supporting your disability claim.
- The appeal level is a critical stage in the appeals process.
By understanding the disability benefits system and seeking help when needed, you can increase your chances of receiving the benefits you deserve. Stay informed, gather all the evidence, and don’t hesitate to seek help when navigating the complex world of disability benefits.
What If You Have Two Appeals?
Let’s say your plan gives you two levels of appeal. That gives you a bit more flexibility.
But don’t get comfortable.
If you decide to handle the first appeal on your own, take it seriously. Be thorough. Include everything you can.
If you lose that first appeal, you must take further action to strengthen your case for the second appeal. Hire a lawyer immediately for the second one. Don’t wait.
The second appeal is your last chance to strengthen the file before the court sees it.
And remember: the insurance company’s goal is to deny your benefits. Your job is to prove they’re wrong.
What Happens After You Exhaust Your Appeals?
Once you’ve completed all required appeals, you have the right to sue the insurance company in federal court. Once you’ve completed all required appeals, you have the right to sue the insurance company in federal district court.
But remember—the judge can only review what’s in your file.
If you submitted a weak or incomplete appeal, the court can’t fix it. The court can’t hear new testimony. The court can’t see new medical records.
That’s why the administrative appeal is not just paperwork. It’s your day in court—without the courtroom.
What If You Miss the Deadline?
You generally have 180 days from the date of your initial denial letter to file your appeal.
Miss that deadline, and your claim is usually dead.
You may lose your right to appeal. You may also lose your right to sue.
Don’t wait. Start gathering records now. Talk to a lawyer as soon as possible.
Final Thoughts: Don’t Waste Your Only Chance
Long-term disability benefits are more than just insurance. They are your financial safety net, and getting your appeal approved is crucial.
Without them, you may not be able to:
- Pay your mortgage
- Keep your car
- Afford medications
- Put food on the table
Don’t risk losing that support because you underestimated the appeal process.
If you only get one appeal, it has to be right.
And even if you get two, you don’t want to waste the first.
Get help early. Make your file strong. Give yourself the best shot at winning.
Need Help With an ERISA Appeal?
At Osterbind Law, we help people fight back after wrongful long-term disability denials. You can start your appeal online for added convenience. We know how to build strong ERISA appeals that hold up in court.
Don’t go it alone.
Call us today or fill out our contact form to schedule a free consultation.
We’ll review your denial letter and help you understand your next steps.
