Why Your Long Term Disability Denial Is Probably an ERISA Case, and Why That Changes Everything
August 26, 2026 |
You paid into a long term disability policy through work for years. You got sick, you stopped working, you filed a claim, and the insurance company denied it. Their letter says you can appeal within 180 days.
Most people treat that appeal as a formality. They write a letter explaining that the denial was unfair, send it in, and wait. That is the single most expensive mistake in this area of law, because in most employer provided policies that appeal is not a formality. It is very likely your only real chance to build your case.
The Federal Law Sitting Behind Your Policy
If you got your long term disability coverage as a benefit through your employer, your claim is almost certainly governed by a federal law called the Employee Retirement Income Security Act, usually shortened to ERISA.
ERISA was written to regulate employee benefit plans, and it brought disability insurance provided through work under federal rules. Those rules displace much of the state insurance law you might otherwise rely on, and they reshape the process in ways that work to the insurer’s advantage if you do not know about them.
Not every policy falls under ERISA. The important exceptions are:
- Government employer plans. If you work for a city, county, the State of California, or a school district, your plan is generally not an ERISA plan.
- Church plans, which are also typically excluded.
- Individual policies you purchased yourself, outside of work. These are governed by California insurance law, which gives you considerably more room, including the possibility of a bad faith claim.
Figuring out which category you are in is the first question, because almost everything that follows depends on the answer.
What ERISA Takes Away
For claims that fall under ERISA, several things are true that surprise people:
You must exhaust the administrative appeal first. You generally cannot go to court until you have completed the insurer’s internal appeal process. Skip it or miss the deadline and your claim can be over regardless of how strong it was.
The record usually closes. This is the one that does the damage. When a case reaches federal court, the judge typically reviews only the evidence that was in the administrative record by the end of the appeal. New doctor reports, new test results, and new expert opinions generally cannot be added later. Whatever you failed to submit during the appeal is simply not part of your case.
There is no jury. A judge decides, on the paper record.
Damages are limited. In an ERISA case the usual remedy is the benefits you were owed, plus possibly attorney fees and interest. The punitive and emotional distress damages available in some insurance disputes are generally not on the table.
Put together, this means the appeal is the case. By the time a lawsuit is filed, the evidence is already fixed.
A California Law That Works In Your Favor
Here is a point that many claimants and some attorneys miss, and it can determine whether you win.
In ERISA cases, how closely a court examines the insurer’s decision depends on whether the policy gave the insurer discretionary authority to interpret the plan and decide claims. If it did, courts have traditionally reviewed the denial only for abuse of discretion, a deferential standard under which an insurer can win even when a judge thinks the decision was wrong. If it did not, review is de novo, meaning the court decides the disability question itself.
California addressed this directly. California Insurance Code section 10110.6 renders discretionary clauses in disability insurance policies void. For policies issued or renewed in California, that provision strips out the language insurers rely on to obtain deferential review.
The practical effect is significant. A California claimant may get de novo review where a claimant in another state with an otherwise identical policy would face the much harder abuse of discretion standard. Whether it applies to your policy depends on where the policy was issued or renewed and other details, but it should be checked in every California long term disability case, and it is worth raising if nobody has mentioned it to you.
How Insurers Actually Deny These Claims
Denials tend to follow recognizable patterns.
The definition of disability changes. Many policies cover you for the first 24 months if you cannot perform your own occupation, then switch to a stricter test of whether you can perform any occupation. A large share of terminations happen precisely at that transition, to people who were being paid without dispute the month before.
A paper review overrides your doctors. The insurer hires a physician who never examines you, reviews your file, and concludes you can work. Your treating doctors said otherwise, but the file now contains a contrary opinion.
Surveillance and social media. A few minutes of video showing you carrying groceries gets characterized as proof you can work full time.
Subjective symptoms get discounted. Conditions like fibromyalgia, chronic fatigue, migraines, and mental health conditions are frequently denied on the basis that the evidence is subjective, even when treatment history is extensive.
Pre existing condition and late filing provisions. Technical policy terms get applied to defeat a claim that is medically sound.
Knowing the pattern tells you what your appeal has to answer. A denial based on a paper review needs to be met with detailed functional evidence from treating providers, not a letter saying the decision was unfair.
What A Real Appeal Contains
An appeal that gives you a chance generally includes:
- The complete claim file, which you have a right to request, so you can see exactly what the insurer relied on
- Detailed statements from treating physicians addressing function, not just diagnosis, in the terms the policy uses
- Objective testing where it exists, including functional capacity evaluations and neuropsychological testing when appropriate
- A direct response to the insurer’s reviewing physician, identifying what they got wrong or never considered
- Vocational evidence about what your occupation actually requires, or what other occupations demand
- Statements from people who see your daily limitations
- Your own detailed account of what you can and cannot do across a normal day
It also has to be submitted within the deadline, and policies contain their own time limits for filing suit afterward that are easy to miss.
Long Term Disability Alongside Your Other Benefits
Most long term disability policies reduce what they pay by other benefits you receive, including Social Security disability. Many policies also require you to apply for Social Security, and some insurers will help you do it, which is not purely generosity since an approval lowers their obligation.
This interaction is worth handling deliberately. A Social Security approval strengthens your position with the insurer, since it is a federal determination that you cannot work. At the same time, the offset and any resulting overpayment to the insurer need to be understood before a lump sum of Social Security back pay arrives and the insurer asks for a large repayment.
California state disability insurance is a separate short term program and should not be confused with long term disability coverage, though the timing of one often runs into the other.
Questions People Often Ask About Long Term Disability Denials
People ask how long they have to appeal. Under ERISA the standard period is 180 days from the denial, which sounds generous and is not, given how much evidence has to be gathered. Start immediately.
Another question is whether they can just file a lawsuit instead. Generally no for an ERISA plan, because you have to exhaust the internal appeal first.
People ask whether they can add evidence later if they lose. Usually not. That is why the appeal carries so much weight.
People ask whether being approved for Social Security disability forces the insurer to pay. It does not, because the policy definition and the Social Security standard are different tests. It is strong evidence and it helps, but it is not automatic.
And people ask about cost. These cases are commonly handled on a contingency basis, so there is no upfront fee and a fee is paid from the recovery.
Contact Our Los Angeles Long Term Disability Attorneys
At Pisegna and Zimmerman Attorneys at Law, we represent people whose long term disability claims have been denied or terminated, and we treat the administrative appeal as the decisive stage it actually is. We request the claim file, find out what the insurer relied on, determine whether your plan falls under ERISA at all, and check whether California’s rule voiding discretionary clauses applies to your policy.
Our firm has over 60 years of combined experience, and we represent claimants across Los Angeles, Sherman Oaks, Long Beach, Norwalk, San Bernardino, Santa Barbara, Bakersfield, and throughout Southern California. Because we also handle Social Security disability, we coordinate both claims rather than letting one create a problem in the other.
If your long term disability benefits were denied or cut off, call our office at (818) 888-8888 before your appeal deadline passes. The window is shorter than it looks, and what goes into that appeal is what you will be judged on.