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Disability Wiki

Long-Term Disability Insurance

If you have long-term disability (LTD) coverage through work or a policy you bought yourself, it may be the main thing replacing your income if you become too disabled to keep working. It is also one of the least understood parts of the disability landscape, partly because the companies that explain it publicly are usually selling something.

People do win these claims, including after a denial. Much of what decides the outcome is within your influence: how your medical record describes what you can and cannot do, whether you meet the deadlines, and how completely you use your appeal.

The short version: LTD is a private insurance contract, not a government benefit. The insurer decides your claim, and the same company pays it. In the US, your internal appeal is usually the only chance to build the record a court will ever see. In Canada, the deadline to sue is short and varies by province. In both places, deadlines matter more than fairness, and getting advice early costs less than getting it late.

How LTD Differs from Government Benefits

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These are separate systems that interact, and confusing them is a common and expensive mistake.

Long-term disability insurance is a contract. An insurer agrees to pay a portion of your income (commonly somewhere around 60 to 70 percent, though this varies by policy) if you meet that policy’s definition of disability. You usually get it through an employer, sometimes through a union or association, sometimes by buying it directly. The insurer decides whether you qualify.

Government disability benefits such as SSDI in the US or CPP Disability in Canada are statutory. Eligibility rules are set by law, decisions are made by a government agency, and there is a public appeal system.

Short-term disability covers a limited period, often weeks to a few months, and typically runs out around the time LTD would begin.

The two systems are connected in a way that surprises people: most LTD policies reduce what they pay by the amount of any government benefit you receive, and many require you to apply for those benefits. Winning SSDI or CPP-D often does not increase your total income, because the insurer’s payment drops by roughly what the government pays. This is normal policy language rather than something going wrong, but it is worth understanding before you count on the combined amount.

Where Are You?

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United States

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Most Workplace Policies Fall Under ERISA

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If your LTD coverage came through a private employer, it is probably governed by ERISA, a federal law. Policies you bought yourself, and plans from government employers and many churches, generally are not, and are governed by state insurance law instead.

The distinction matters more than it sounds, because of one feature: in ERISA cases, courts are generally limited to reviewing the evidence that was already in the insurer’s file when it made its final decision, and new evidence usually cannot be added later. How strictly this applies varies between courts. Many plans also give the insurer discretion to interpret the policy, and courts commonly review those decisions under a deferential standard rather than deciding the question fresh, though a number of states restrict these discretionary clauses.

The practical consequence is the single most important thing on this page: your internal appeal is where your case gets built. By the time a lawsuit starts, the record is usually closed. An appeal treated as a formality can quietly decide the outcome years before a judge sees it.

What the Federal Claims Rule Requires

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The claims procedure regulation, 29 CFR 2560.503-1, sets minimum requirements, and it includes protections written specifically for disability claims. Verified against the current regulation text as of August 2026:

  • Independence and impartiality. For disability claims, decisions about hiring, compensation, termination, or promotion of the people involved, including claims adjudicators and medical or vocational experts, must not be based on the likelihood that the person will support denying benefits (paragraph (b)(7)).
  • Initial decision timing. The plan must decide within 45 days, extendable by up to 30 days, and in some circumstances by a further 30 days, with notice each time (paragraph (f)(3)).
  • At least 180 days to appeal an adverse determination (paragraph (h)(4), which applies the group health plan timeline in (h)(3)(i) to disability claims).
  • A genuinely different reviewer. The appeal must not defer to the original decision and must be handled by someone who is neither the original decision-maker nor that person’s subordinate (paragraph (h)(3)(ii), applied through (h)(4)).
  • Advance access to new evidence. Before denying an appeal, the plan must give you, free of charge, any new or additional evidence it generated or relied on, and any new rationale, early enough that you have a reasonable chance to respond (paragraphs (h)(4)(i) and (h)(4)(ii)). This provision is easy to overlook and directly useful: it means a report written to justify denying you is something you can see and rebut before the decision, not after.
  • Appeal decision timing. Generally 45 days, with a limited extension available (paragraph (i)(3)(i), applying (i)(1)(i)).
  • Deemed exhaustion. If a plan fails to strictly adhere to these requirements on a disability claim, you are generally treated as having exhausted the plan’s internal process and may pursue remedies without further internal appeals, subject to a narrow exception for minor errors (paragraph (l)(2)).

You are also entitled to request the documents relevant to your claim, including your claim file and the plan documents. Asking for these in writing early is one of the cheapest useful things you can do, because the definition of disability that decides your claim is in a document you may never have been given.

If Your Policy Is Not Governed by ERISA

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Individually purchased policies and public employee plans generally fall under state law, which often allows a broader range of claims and remedies than ERISA. Your state insurance regulator handles complaints. The NAIC directory of state insurance departments lists the office for each state.

Canada

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It Is a Contract Dispute

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Canadian LTD is regulated provincially and disputes are generally handled as breach of contract claims in the courts, rather than through a federal framework like ERISA. Coverage usually comes through a group plan at work, sometimes through an individual policy. Insurers run internal appeals, but unlike the US system, an internal appeal is generally not a required step before suing.

Limitation Periods Are Short, and the Clock May Already Be Running

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This is the part that causes the most irreversible harm, so it is worth stating plainly rather than diplomatically.

The deadline to start a court claim is set by provincial limitations legislation and is measured in years, not decades. The date the clock starts is not always the date you think, and it may run from the insurer’s denial rather than from the end of an appeal. Filing an internal appeal does not necessarily pause it.

The failure mode is specific and common: someone spends a year or more in repeated internal appeals, in good faith, and discovers afterward that the period to sue expired while they were appealing.

Because these rules vary by province and the start date can be contested, this page does not state a number for your situation. Check your province’s limitations legislation and get advice from a lawyer in your province early, ideally as soon as you receive a denial, even if you intend to appeal internally. An initial consultation is often free, and the question of how long you have is exactly the question worth asking first.

Complaints and Escalation

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Every insurer has an internal complaints process ending in a final position letter. If you are unsatisfied with that outcome, or the insurer has not responded within its stated timeframe, the OmbudService for Life and Health Insurance (OLHI) provides free, independent, bilingual dispute resolution for consumers of Canadian life and health insurers, including disability coverage. Its complaints process generally requires a final position letter first.

Using OLHI does not stop a limitation period from running. Treat it as a parallel route, not a substitute for legal advice about deadlines.

CPP Disability interacts with LTD the same way SSDI does in the US: most policies offset against it, and many require you to apply.

Other Countries

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Employer-provided income protection insurance exists in many countries under different names, including income protection in the UK, Australia, and Ireland, where it may sit alongside statutory schemes. The general patterns on this page, meaning definitions of disability, offsets against public benefits, medical examinations, and short deadlines, tend to recur, but the legal framework does not. If you know how this works where you live, that section is missing and we would like your help writing it.

What Insurers Look At

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These patterns show up across policies and countries. None of them mean a claim is doomed, and knowing about them in advance is most of the advantage.

The definition of disability changes partway through. Many policies pay at first if you cannot do your own occupation, then switch after a set period, commonly around 24 months, to a stricter test asking whether you can do any occupation you are reasonably suited for. Claims that were being paid without dispute can end at that point because the test changed, not because your condition did. The date is in your policy, and it is worth knowing years ahead.

Some conditions face a shorter cap. Many policies limit benefits, often to around 24 months, for claims based on mental health conditions, and sometimes for conditions the policy describes as self-reported or lacking objective findings. Exact wording varies and the wording is what governs.

Demands for objective evidence. Insurers frequently ask for objective proof of conditions that have no single objective test, including ME/CFS, fibromyalgia, long COVID, chronic pain, and most mental health conditions. See invisible, fluctuating, and episodic disability for how this problem shows up across systems.

Independent medical examinations. Policies typically allow the insurer to require an examination by a doctor it selects and pays. You are usually entitled to know what happens to the report, and in the US the disability rules above give you a route to see and respond to it before a final appeal decision.

Surveillance and social media. Video surveillance and review of public social media are established practice in this industry. A single photograph of a good hour is routinely presented as though it described every hour. This is not a reason to hide, and it is a reason to make sure your medical records describe your function accurately, including variability and what activity costs you afterward.

Protecting Your Claim

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Concrete steps, roughly in order of how much difference they make.

Get the policy itself, not the summary. Ask in writing for the full policy or plan documents. Read the definition of disability, the elimination period before payments start, the own-occupation period, any condition-specific limits, and the offset provisions.

Make sure your records describe function, not just diagnosis. A diagnosis rarely decides these claims; capacity does. What is useful is specific and measured: how long you can sit, stand, concentrate, or use your hands, how often symptoms interrupt you, what happens the day after exertion, and what you have already tried. Ask your clinicians to record limitations in those terms. See proving disability, which covers the same evidence problem across systems.

Keep your own record. Dated symptom and activity logs, copies of everything sent and received, and notes of phone calls with names and dates. Insurers keep a file on your claim; keeping your own is reasonable.

Calendar every deadline the day a letter arrives. Appeal windows and limitation periods are the failure point in most lost claims, and they are the one part of this process that is entirely predictable.

Treat the appeal as the whole case. Especially under ERISA, submit everything you want considered before the final decision: updated records, treating clinicians’ opinions on function, a functional capacity evaluation if one is appropriate and available, statements from people who see you daily, and a direct response to each reason the denial gave. Ask for the claim file first, so you are answering the actual reasoning rather than a summary of it.

Get advice early, and ask about cost up front. Many lawyers in this field work on contingency and offer free initial consultations. Early advice is most valuable before an appeal is filed, not after the record closes. See finding legal aid.

This Page Is Not Legal Advice

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The rules here are general, they vary by jurisdiction and by policy, and the specific wording of your contract governs your claim. Deadlines in particular are unforgiving, and a missed one usually cannot be undone. Use this page to ask better questions, then get advice from someone licensed where you live.

Resources

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United States

Section titled “United States”

Canada

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Contribute to This Page

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Have you been through an LTD claim, an appeal, or a lawsuit? The details that help most are the ones nobody publishes: what the insurer actually asked for, what evidence moved the decision, and what you wish you had known at the denial letter. We especially want to hear from people outside the US and Canada, whose systems this page does not yet cover. See How to Contribute.

This page centers disabled people’s expertise and is informed by disabled-led organizing globally. For questions or to suggest additions, see How to Contribute.

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