When you file a long-term disability claim, you’re usually asking questions like:
- Am I sick?
- Am I in pain?
- Why can’t I work like I used to?
The insurance company is asking something very different.
I’m Brandon Osterbind, an injury and disability attorney in Virginia. I help people whose long-term disability claims have been denied. And once you understand how insurance companies actually review disability claims, their denial letters start to make a lot more sense.
This isn’t a medical process.
It’s a legal one.
1. Insurance Companies Look for Consistency — Not Compassion
One of the first things insurers examine is consistency.
They compare:
- Your medical records
- Your claim forms
- Your appeal paperwork
- Your job description
If one document says you can sit for six hours, another says two hours, and a third doesn’t mention sitting at all, the insurance company doesn’t try to resolve that confusion.
They resolve it against you.
Inconsistencies are one of the most common reasons disability claims are denied, even when the underlying condition is real.
2. They Want “Objective” Support . . . Even for Subjective Conditions
Many disabling conditions are inherently subjective:
- Chronic pain
- Fatigue
- Brain fog
- Migraines
- Autoimmune disorders
Insurance companies don’t deny that these conditions exist. Instead, they argue that there isn’t enough objective support surrounding them.
That means they look for things like:
- Clinical findings
- Imaging
- Neuropsychological testing
- Functional Capacity Evaluations (FCEs)
- Detailed physician explanations tying symptoms to limitations
If your records only say “patient reports pain” without explaining how that pain limits function, insurers will argue the evidence is insufficient.
3. Disability Is About Function, Not Diagnosis
This is one of the most misunderstood parts of the process.
A diagnosis does not equal a disability.
The insurance company’s real questions are:
- What can this person still do?
- For how long can they do it?
- Can they sit, stand, concentrate, or maintain pace?
- Can they work eight hours a day, five days a week?
If the file doesn’t clearly answer those questions, the insurer fills in the blanks — and not in your favor.
4. They Evaluate Your Occupation, Not Your Employer
Many people assume the insurer looks at whether they can do their specific job.
Most policies don’t ask that.
They ask whether you can perform the main duties of your occupation as it is generally performed in the national economy.
That means insurers may rely on:
- Generic job descriptions
- National occupational databases
- Vocational classifications
If your claim doesn’t explain why those general duties are no longer possible for you, the insurer may conclude you’re capable of working — even if your actual job was far more demanding.
5. They Look for Gaps And Use Them Against You
Insurance companies closely examine the timeline of your care.
They look for:
- Gaps in treatment
- Gaps in complaints
- Missed appointments
- Long stretches without documentation
Even when those gaps have reasonable explanations, insurers often argue that they prove your condition isn’t severe or ongoing.
To them, gaps equal doubt.
6. They Are Always Thinking About Court
This part is critical.
Under ERISA, the claim file becomes the record.
If it’s not documented in the file, the judge will NEVER see it later.
That’s why insurers are methodical.
It’s why denials are carefully written.
And it’s why many legitimate claims fail.
They aren’t just reviewing your claim.
They’re building a defense.
Three Key Takeaways
If you remember nothing else, remember this:
1. Disability claims are reviewed through a legal lens, not a medical one
Insurance companies are defending claims, not helping claimants.
2. Claims are about function, consistency, and documentation
Not just diagnoses.
3. The record is everything
Once the file closes, it’s often too late to fix what’s missing.
Final Thoughts: Understanding the Process Changes Outcomes
Many people are genuinely unable to work, and still lose their benefits because the evidence doesn’t line up the way insurance companies expect.
Understanding what insurers are really looking for can completely change the outcome of a claim or appeal.
If your long-term disability claim has been denied, or you’re in the middle of an appeal and aren’t sure what evidence is missing, we’re happy to help. We can review your file and explain how these claims are actually evaluated.
And if you found this helpful, be sure to follow along. We regularly share information about disability law, insurance tactics, and the mistakes that cost people their benefits.
