The Appeals Process for Mental Health-Related Long-Term Disability Claims

Navigating the appeals process for mental health-related long-term disability (LTD) claims can be particularly challenging. Unlike physical conditions that can be documented with imaging and lab results, mental health disorders rely on more subjective assessments that insurers often undervalue or dismiss. Insurers may also use various tactics to discredit claims, such as surveillance, relying on their own medical experts over treating physicians, and highlighting inconsistencies in medical records.

When benefits are denied, claimants may feel discouraged, but a strong appeal can turn things around. Here’s a detailed guide to appealing a mental health-related LTD denial and increasing your chances of success.

1. Understand Why Your Claim Was Denied

Carefully review your insurance company’s denial letter. Insurers are required to give reasons for denials, but their explanations are often vague or full of complex language. Common reasons for denial include:

• Insufficient Evidence: Insurers may claim that your condition isn’t well-documented or that your symptoms aren’t supported by objective findings.
• Policy Exclusions or Limitations: Many policies include a 24-month cap on mental health claims unless specific exceptions apply.
• Failure to Meet the Policy’s Definition of Disability: Insurers may argue that you can still work in some capacity or that your condition doesn’t meet their criteria for disability.

Understanding the exact basis for the denial is critical to crafting a strong appeal.

2. Gather Evidence from Mental Health Professionals

Mental health claims are often denied due to a perceived lack of objective evidence. Strengthen your appeal by gathering substantial documentation from mental health professionals, including:

• Psychiatric or Psychological Evaluations: Detailed reports from a psychiatrist or psychologist describing the severity and duration of your condition. Ask your provider to complete a Residual Functional Capacity (RFC) form to describe your limitations.
• Treatment Records and Progress Notes: Regular therapy and medication records that show consistent symptoms and efforts to improve.
• Functional Capacity Evaluations: Some doctors specialize in functional evaluations that document mental and cognitive limitations that affect work performance. A Functional Capacity Evaluation (FCE) from a mental health professional may help address insurer concerns.

In addition, neuropsychological testing may be useful, especially for claimants with cognitive impairments due to conditions such as major depression or PTSD.

3. Document How Mental Health Symptoms Affect Daily Functioning

A major hurdle in LTD mental health claims is proving how symptoms affect daily functioning. To strengthen your appeal:

• Keep a symptom diary detailing how mental health conditions affect your ability to work, concentrate, interact with others, and perform daily tasks.
• Include real-life examples, such as missing appointments, struggling to complete household tasks, or not being able to leave the house due to anxiety.
• If applicable, provide job performance reviews or statements from your employer that shows a decline in productivity or increased absenteeism.

4. Strengthen Your Appeal with Statements from Family, Friends, or Coworkers

Third-party testimony provides powerful first-hand accounts of how your mental health condition affects your daily life. Ask family members, close friends, or coworkers to write statements describing their observations of:

• Changes in your ability to perform daily tasks.
• Difficulties concentrating, communicating, or regulating emotions.
• Any noticeable changes in behavior over time.

These statements can be particularly effective in showing the insurer how your condition manifests outside of clinical settings.

5. Address the Insurer’s “Lack of Objective Evidence” Claim

Insurers often deny mental health LTD claims based on a purported lack of objective evidence. While mental health conditions don’t show up on MRIs or blood tests, claimants can counter this claim by providing:

• Consistent, long-term treatment records from licensed professionals.
• Structured clinical assessments, such as the Beck Depression Inventory (BDI) or the Generalized Anxiety Disorder 7-item scale (GAD-7), which are standard diagnostic tools.
• Neuropsychological evaluations when cognitive issues, such as memory or focus problems, are a concern.

By gathering structured medical evidence, you can strengthen the legitimacy of your claim.

6. Prepare for Required Examinations

The insurance company may require an Independent Medical Examination (IME) or Functional Capacity Evaluation. However, these are often conducted by doctors hired by the insurer, who may downplay your condition. To protect yourself:

• Document everything that occurs during the examination.
• Bring a witness, if allowed, to ensure fair treatment.
• Make sure the doctor has access to your full medical records so they cannot claim a lack of medical history.

If you suspect bias in the IME report, a disability lawyer can challenge it during the appeals process.

7. Understand ERISA Appeal Deadlines

If your LTD policy is governed by the Employee Retirement Income Security Act (ERISA), you usually have 180 days from the date of the denial to file an appeal. But you should verify any time limits in your denial letter and/or disability insurance policy.

An appeal may be your only chance to submit new evidence before a lawsuit, so it’s important to include all supporting documentation. Failure to meet this deadline could result in the loss of your right to benefits.

8. Legal Help Can Strengthen Your Appeal

The appeals process for mental health-related LTD claims can be complex, especially when dealing with insurer tactics designed to discredit mental health conditions. At the Ortiz Law Firm, we have successfully helped claimants across the United States appeal wrongful LTD denials.

We can:

• Obtain expert medical opinions to counter the insurer’s case.
• Ensure compliance with ERISA time limits and procedural requirements.
• Draft a comprehensive appeal letter that directly addresses the reasons for the denial.

Experienced disability attorney Nick Ortiz knows how to fight back against insurance companies and get results. Here are just a few cases where we have successfully overturned benefit terminations:

• MetLife Improperly Terminated Claim After 24 Months: MetLife initially approved benefits but terminated them after 24 months, citing a mental health limitation in the policy. The claimant provided evidence of a covered exception, but MetLife required “objective” evidence beyond what was required. We appealed, demonstrating the claimant’s qualifying diagnosis, and MetLife reinstated the claim within weeks.
• New York Life Reinstates Benefits for Medical Billing Specialist: After approving short-term disability, New York Life terminated benefits based on a peer review. Our appeal demonstrated that pain and mental health symptoms caused frequent interruptions to work, medication side effects impaired function, and poor sleep affected mood. New York Life reversed the termination and approved LTD benefits.

An Experienced Long-Term Disability Attorney Can Help

Filing a strong appeal for a mental health-related LTD claim requires perseverance, thorough documentation, and a strategic approach. If your claim has been denied, don’t lose hope—you have the right to appeal the decision. Consulting with a disability attorney can greatly improve your chances of overturning the denial.

If you need assistance with your appeal, contact our office today for a free case evaluation. We can prepare a strong appeal and fight for the benefits you deserve. Call (888) 321-8131 to schedule a free case evaluation today.