ERISA Disability Appeals in Pennsylvania: Building the Record

Step one: get the claim file

Before writing anything, request the entire administrative record. You are entitled to it, and it usually contains material the denial letter never mentions:

• The policy itself, including the exact definition of disability and any limitations.
• The file reviewing physician’s report, and crucially the questions they were asked.
• Which of your medical records were actually sent to that reviewer, and which were not.
• Internal notes, claim diaries and any surveillance obtained.
• The vocational analysis, if one was done.

Reviewers being sent an incomplete record is common, and a denial resting on records the reviewer never saw is a strong argument.

Step two: answer the actual reason

Read the denial closely. “Insufficient objective evidence” requires a different response from “able to perform sedentary work” or “excluded as a pre-existing condition.” Appeals that restate how ill someone is, without engaging with the stated basis, fail.

Step three: build evidence that speaks to function

Insurers do not dispute that you have a diagnosis. They dispute what you can still do. Evidence that addresses function is what moves these claims:

• Functional capacity evaluation, measuring sitting, standing, lifting and tolerance over a day.
• Treating specialist opinions that describe limitations concretely rather than concluding disability.
• Neuropsychological testing where cognition or fatigue is central.
• Vocational assessment, applying the policy’s own definition to your restrictions.
• Daily activity records, kept over weeks, showing variability rather than a snapshot.
• Statements from family and former colleagues describing what changed.

Step four: preserve everything for court

Because the record closes, the appeal should anticipate the lawsuit. That means raising every argument, including procedural ones: whether deadlines were met, whether a full and fair review occurred, whether the insurer operated under a conflict of interest by both deciding and paying claims.

Do not let the deadline pass while gathering

Testing takes time to arrange and specialists are slow. Extensions are sometimes available, and asking early is far better than asking late. The 180 days is not extended by the fact that your doctor has a three month waiting list.