When an insurance company denies a claim for long-term disability (LTD) benefits under an employer-sponsored group plan, the appeal process is often the claimant’s most critical—and sometimes only—opportunity to secure benefits. These plans are usually governed by the Employee Retirement Income Security Act of 1974 (ERISA), a federal law with strict procedural rules that heavily favor insurers.
A key element of a successful ERISA disability appeal is the involvement of the claimant’s treating doctors. At the Law Offices of Kevin M. Zietz, PC, we often encounter valid claims being denied due to inadequate development or presentation of medical evidence during the appeal.
Why Treating Physicians Matter in ERISA Disability Cases
Treating physicians are uniquely positioned to support a disability claim because they:
- Have an ongoing treatment relationship with the patient
- Observe symptoms over time, including flare-ups and variability
- Understand how medical conditions affect daily and occupational functioning
- Can explain why a claimant cannot reliably sustain full-time work
Although ERISA does not require insurers to automatically defer to treating physicians, courts often evaluate whether insurance companies fairly considered treating doctors’ opinions—especially when those opinions are consistent, well-reasoned, and supported by the medical record.
Medical Records Alone Are Often Not Enough
Many disability claims get denied even when the insurance company agrees with the diagnosis. Insurers frequently claim that: “The medical records do not support functional impairment.” This is because medical records focus on documenting treatment, not assessing work ability. Treating doctors are essential in providing medical opinions that clarify how a condition affects the claimant’s capacity to perform job duties, such as:
- Sitting, standing, walking, or lifting
- Concentrating or maintaining pace
- Managing pain, fatigue, or cognitive symptoms
- Maintaining reliable attendance and productivity
Without this type of functional analysis, insurers frequently conclude that a claimant can still perform “sedentary” or “light” work.
Addressing the Insurance Company’s Reasons for Denial
A strong ERISA appeal must directly respond to the insurance company’s stated reasons for denying benefits. Treating physicians can help rebut common insurer arguments, including:
- Alleged lack of “objective” medical evidence
- Claims that symptoms are subjective
- Assertions that treatment is conservative
- Reliance on the fact that a condition is “stable”
A treating doctor can explain, for example, why certain conditions do not produce definitive objective findings, why conservative treatment is medically appropriate, or why stability does not equate to an ability to work full-time.
Functional Capacity Is the Core Issue in ERISA Claims
Under ERISA, disability determinations focus on functional capacity, not simply diagnosis. Treating physicians can provide critical insight into:
- Physical limitations (e.g., sitting, standing, lifting, fine motor use)
- Cognitive or psychological impairments (e.g., focus, memory, stress tolerance)
- The need for unscheduled breaks, reduced hours, or absences
- The impact of symptom variability over a normal workweek
These opinions are particularly persuasive when they are tied directly to the demands of the claimant’s own occupation—or, where applicable, any occupation.
Countering Insurance Company Reviewing Doctors
Insurance companies frequently rely on doctors who:
- Conduct only paper reviews of the file
- Never examine the claimant
- Perform brief independent medical examinations
Treating physicians can counter these opinions by identifying inaccuracies, explaining why short evaluations fail to capture real-world limitations, and reinforcing conclusions based on sustained clinical observation. Courts often question denials that rely heavily on non-examining reviewers while discounting treating providers without a reasonable basis.
Timing Is Critical Under ERISA
ERISA disability claims are governed by strict procedural rules. In most cases, new evidence cannot be submitted after the administrative appeal is denied. This makes it essential that treating physician opinions, clarifications, and rebuttals be obtained and submitted during the appeal stage.
Failing to include this evidence during the appeal can significantly limit a claimant’s ability to challenge the denial later in court.
Helping Treating Doctors Provide Effective Support
Treating physicians are medical professionals—not ERISA specialists. Effective appeals often involve guiding doctors by providing:
- The insurance company’s denial letter
- The policy’s definition of disability
- A description of the claimant’s job duties
- Focused questions about functional limitations
Doctors do not need to offer legal conclusions. Their role is to clearly explain medical facts and work-related limitations in a way that directly addresses the insurer’s stated concerns.
How an Experienced ERISA Disability Attorney Can Help
Coordinating treating physician evidence in an ERISA appeal requires legal and medical strategy. At the Law Offices of Kevin M. Zietz, PC, we work closely with clients and their treating providers to ensure that:
- Medical opinions address the correct legal standard
- Insurer arguments are directly rebutted
- The administrative record is fully developed before the appeal deadline
If your long-term disability claim has been denied, experienced legal representation can make a meaningful difference.
Have your long-term disability benefits been denied?
Contact the Law Offices of Kevin M. Zietz, PC , to discuss your ERISA disability appeal. We focus on representing individuals whose disability claims have been wrongfully denied by insurance companies and on building strong appeals supported by evidence from treating physicians.
Disclaimer
This blog post is for informational purposes only and does not constitute legal advice. Reading this article does not create an attorney-client relationship. Every disability claim is unique, and outcomes depend on the specific facts and policy language involved. If you have questions about your claim, you should consult with a qualified ERISA disability attorney like Kevin M. Zietz.
