Long Term Disability Denied in Pennsylvania: Reading the Letter Properly
The stated reason determines the response, and the deadline is on the page.
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The denial letter tells you three things: the specific reason, the deadline to appeal, and your right to the claim file. For an employer plan the appeal deadline is generally 180 days, and the reason given determines what evidence the appeal has to contain.
The four things to find in the letter
- The specific reason. Not the summary, the actual basis relied on.
- The appeal deadline. Usually 180 days for an ERISA plan. Diary it immediately.
- The policy provision cited. Definition of disability, an exclusion, or a limitation.
- The statement of your right to the claim file. Request it the same week.
Common reasons and what each requires
| Reason given | What the appeal needs |
|---|---|
| Insufficient objective evidence | Functional testing, specialist opinion on function, consistent treatment records |
| Able to perform your occupation | A vocational analysis of what your job actually required, against your restrictions |
| Able to perform any occupation | Same, applied to the alternative jobs the insurer identified |
| Pre-existing condition | Treatment history through the lookback period, and the precise policy wording |
| Mental health limitation reached | Evidence of a co-existing physical condition independently disabling |
| Failure to provide information | Identify what was actually sent and when. This one is frequently wrong |
What to do this week
- Diary the appeal deadline and count backwards from it.
- Request the complete claim file in writing.
- Request the full policy document, not the summary booklet.
- Keep treating. A gap after a denial is used as evidence you recovered.
- Start arranging functional testing now, because scheduling takes weeks.
What not to do
Do not send a short letter saying you disagree and asking them to reconsider. That is an appeal, it consumes your one opportunity, and it closes the record with nothing in it.
Do not miss the deadline while gathering evidence. Ask for an extension early if you need one.
Do not assume a denial means the claim was weak. Denial is a normal early outcome, and many are reversed on a properly built appeal.
The attorneys who handle these cases
Every one of these bar numbers is searchable on the Pennsylvania Disciplinary Board register. The person who takes your call is the person at your hearing.
-
Kenneth R. Schuster
Founding Member
Read Kenneth’s background -
Justin M. Bernstein
Associate
Read Justin’s background -
Christopher D. Gasda
Associate
Read Christopher’s background -
Anthony S. Pinnie
Of Counsel
Read Anthony’s background -
Joseph J. Jachetti
Associate
Read Joseph’s background -
Andrew Valentin
Associate
Read Andrew’s background
Questions people ask us about this
What should I look for in the denial letter?
The specific reason relied on, the appeal deadline which is usually 180 days for an employer plan, the policy provision cited, and the statement of your right to the claim file. Those four things determine everything you do next.
Can I just write and ask them to reconsider?
You can, and it is usually a serious mistake. That letter counts as your appeal, it consumes the one opportunity you have, and it closes the administrative record with nothing in it. Under ERISA a court will then review that empty record.
They said there is insufficient objective evidence.
That requires functional evidence rather than more diagnosis. Functional capacity testing, a treating specialist's opinion describing concrete limitations, and consistent treatment records are what answer it. Repeating how unwell you feel does not.
Should I keep going to the doctor after a denial?
Yes, and it is important. A gap in treatment following a denial is routinely used as evidence that you recovered or that the condition was never disabling. If cost is the obstacle, say so, because there are usually practical routes.
Does a denial mean my claim was weak?
No. Denial is a normal early outcome in these claims, and a significant proportion are reversed on a properly built appeal. What matters is what goes into the record during the appeal window.
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