When a long-term disability claim is denied or benefits are terminated, the case enters the administrative review and appeals process. This phase happens inside the insurance company, not in court, and it is often the most important stage of the entire claim. For most employer-provided LTD plans, this process is governed by ERISA rules, which strictly limit what evidence can be used later.

Step 1: Administrative review

After a denial or termination, the insurer issues a written explanation outlining the reasons for its decision. During administrative review, the insurer may:

• Re-examine medical records and claim forms
• Order file reviews or independent medical exams (IMEs)
• Rely on surveillance, vocational opinions, or internal reviewers

At this stage, the insurer is building a record to justify its decision, not reevaluating the claim neutrally.

Step 2: Administrative appeal

The appeal is the claimant’s opportunity to respond—and it is usually the last chance to submit evidence. A proper appeal:

• Addresses each reason for denial directly
• Adds medical opinions explaining functional work limitations
• Rebuts IMEs, surveillance, and insurer-paid reviews
• Clarifies inconsistencies and documents symptom variability

Once the appeal decision is issued, the administrative record closes.

Why this process matters

If the claim later goes to court, the judge will typically review only the administrative record created during review and appeal. New medical records, explanations, or testimony usually cannot be added. That means mistakes, gaps, or missing evidence during the administrative phase can permanently weaken the case.

Bottom line

The LTD administrative review and appeals process is not just paperwork—it is a trial on paper that determines whether benefits continue and whether a case can succeed in court. Treating this stage strategically is critical to protecting long-term disability benefits.