The 8 Most Common Reasons Long-Term Disability Claims Get Denied, and How to Fight Each One

Long-term disability denials rarely happen without a stated reason. Insurance companies are required under ERISA to provide written explanations for their decisions, and while the language is often dense and legalistic, the underlying reasons tend to fall into a small number of recurring categories. Understanding the most common denial reasons, and what it takes to push back on each one, gives you a concrete roadmap for your appeal.

1. Insufficient Medical Evidence

This is the single most common reason LTD claims are denied, and it’s the one most within a claimant’s control to address. Insurance companies require objective, measurable documentation showing that your condition prevents you from performing your job duties. Visit notes that record your symptoms without describing their functional impact, how long you can sit, stand, concentrate, or perform specific tasks, are often treated as inadequate.

How to fight it: Work with your treating physician to produce detailed functional limitation assessments tied directly to your job requirements. For conditions involving pain, fatigue, or cognitive symptoms, specialist evaluations and standardized testing can provide the objective documentation insurers claim is missing. The FAQs on fighting a denied LTD claim address documentation strategy in practical terms that most claimants find useful.

2. Dispute Over the Definition of Disability

Most LTD policies use different definitions at different stages of the claim. For the first 24 months, coverage typically applies under an “own-occupation” standard, you can’t perform your specific job. After that, most policies shift to “any-occupation”, you must prove you can’t perform any job for which you’re reasonably qualified by training, education, or experience.

Insurers frequently deny or terminate claims at the 24-month transition by arguing that while you can’t perform your prior occupation, you could perform some other occupation in the national economy.

How to fight it: A vocational expert can assess whether the jobs the insurer claims you could perform are realistic given your actual limitations, your age, your work history, and local labor market conditions. A generic clerical role that theoretically exists in the national economy is very different from a job you could actually obtain and sustain.

3. Pre-Existing Condition Exclusions

Many LTD policies exclude coverage for disabilities related to conditions that were diagnosed or treated within a specified look-back period before your coverage began, typically three to six months. Insurers frequently apply these exclusions broadly, arguing that any condition with any historical connection to a pre-existing diagnosis falls outside coverage.

How to fight it: The key question is whether your current disabling condition is actually the same condition that was treated during the look-back period, or whether it’s a separate or worsened condition. Medical records establishing the timeline and progression of your condition, along with expert opinion where necessary, can often establish that the exclusion doesn’t apply as broadly as the insurer claims.

4. Failure to Follow Prescribed Treatment

If you’ve missed medical appointments, failed to fill prescriptions, or discontinued a prescribed course of treatment, the insurer may argue that your condition could be improved with proper treatment, and therefore that your current disability isn’t attributable to the condition itself but to your non-compliance.

How to fight it: Document every instance of treatment compliance carefully. If there were valid reasons you couldn’t follow prescribed treatment, cost, side effects, access issues, or medical contraindications, those reasons need to be documented in your medical records. Your physician can also provide a statement clarifying why certain treatments weren’t pursued or why they wouldn’t have changed your functional status.

5. Biased Independent Medical Examination Results

When an insurer orders an Independent Medical Examination, the examining physician is selected, scheduled, and paid by the insurance company. IME reports have a well-documented tendency to minimize claimants’ conditions and support denial decisions. If the IME contradicts your treating physician, the insurer will typically cite it as justification for denial.

How to fight it: Your treating physician should respond in writing to the IME report, addressing its conclusions specifically and explaining why the IME’s findings don’t accurately reflect your condition or functional limitations. In complex cases, retaining an independent specialist to conduct their own evaluation provides a countervailing expert opinion. Attorneys who regularly handle long-term disability denial appeals routinely work with medical and vocational experts to rebut insurer-sponsored IME reports.

6. Surveillance Evidence

Physical surveillance and social media monitoring are standard practice for LTD insurers. A single photograph, a check-in, or a brief video clip showing you performing an activity that appears inconsistent with your claimed limitations can be used as a basis for denial or termination. The context, that you did this once on a good day and spent three days recovering afterward, rarely makes it into the insurer’s report.

How to fight it: If surveillance evidence appears in your claim file, your attorney can challenge how it was gathered and how it’s being interpreted. Your treating physician can provide a statement explaining the episodic nature of your condition, that people with your diagnosis may have occasional periods of higher functioning that don’t reflect their overall capacity. The LTD denial appeal checklist from Kantor & Kantor includes specific guidance on how to address surveillance evidence as part of a comprehensive appeal strategy.

7. Missed Deadlines and Administrative Errors

ERISA imposes strict procedural deadlines on every stage of the disability claims process, and insurance companies enforce them without flexibility. A late filing, an incomplete form, or a missed response to an insurer’s request for additional documentation can provide grounds for denial that have nothing to do with the merits of your medical condition.

How to fight it: Prevention is the best strategy here, calendar every deadline and submit everything with documentation of the date and method. If a deadline was missed due to circumstances related to your disability or to insurer error, there may be grounds to challenge the procedural denial. Consult an attorney immediately if a procedural issue surfaces in your claim.

8. Occupation Misclassification

Some insurers evaluate disability claims by comparing a claimant’s limitations against a generic description of their occupation as it exists in national labor databases, not against what the claimant actually did in their specific role. If your job involved unusually demanding physical or cognitive requirements that aren’t captured in the generic description, you may be denied even though your actual position was beyond your functional capacity.

How to fight it: Detailed documentation of your specific job duties, from your employer, your own records, and former colleagues if necessary, can establish that your actual occupation was more demanding than the insurer’s generic classification. Vocational experts can also provide opinions on how your specific role differs from national occupational averages.

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Regardless of which denial reason applies to your situation, the path forward runs through the same gate: a well-constructed administrative appeal that directly addresses the insurer’s stated reasons with targeted evidence. If your denial came from a major carrier like Anthem, working with attorneys who specifically handle Anthem LTD denials and know the carrier’s specific patterns can materially improve your odds. And if you’re unsure where to start, a free case review for LTD denial can help you identify the most important issues in your specific claim.

A denial letter is the opening argument, not the verdict.