When you need to apply for long term disability benefits due to a serious illness, injury, or medical condition it is very important to submit a strong claim. Working with an experienced long term disability attorney can make all the difference.
Most ERISA disability cases are won or lost before a lawsuit is ever filed. The evidence you submit during the administrative appeal is usually the only evidence a judge will see. If you are challenging a denial or termination of long-term disability benefits in Wisconsin, Illinois, or Indiana, here is how Seventh Circuit law suggests you build the strongest possible case.
Build the record now.
When a plan gives the insurer discretion, the court generally reviews only the evidence the insurer had when it made its final decision. Perlman v. Swiss Bank Corp. Comprehensive Disability Prot. Plan, 195 F.3d 975, 981–82 (7th Cir. 1999). A strong medical opinion obtained after the final denial may never be considered. Treat the appeal as your trial.
Start by requesting your complete claim file, which the insurer must provide free of charge. 29 C.F.R. § 2560.503-1(h)(2)(iii). You generally have 180 days to appeal a disability denial. Id. § 2560.503-1(h)(4). Use that time to find the gaps the insurer identified and fill them. If you need more time to gather records, ask for an extension in writing before the deadline.
Tie the medical evidence to what you can and cannot do
A diagnosis alone rarely wins an ERISA case. Insurers deny claims by conceding the condition but disputing whether it prevents you from working. The strongest evidence explains your functional limits: how long you can sit, stand, lift, concentrate, or keep a schedule, and why.
Ask your treating physicians for detailed narrative letters that connect objective findings to specific restrictions and to the material duties of your job or any occupation, as your policy defines disability. Insurers are not required to defer to treating doctors, but they may not arbitrarily refuse to credit reliable evidence, including a treating physician’s opinion. Black & Decker Disability Plan v. Nord, 538 U.S. 822, 834 (2003). The Seventh Circuit has reversed denials where the insurer brushed aside consistent treating-physician opinions without a reasoned explanation. Holmstrom v. Metro. Life Ins. Co., 615 F.3d 758, 775–78 (7th Cir. 2010).
Consider a functional capacity evaluation and a vocational expert’s report. Together, they translate medical restrictions into the practical question the policy asks: can you perform the job?
Document pain, fatigue, and other subjective symptoms
Conditions like chronic pain, fibromyalgia, and chronic fatigue are frequent targets for denial because they lack dramatic test results. The Seventh Circuit has recognized that the absence of objective proof does not make these conditions any less disabling. Hawkins v. First Union Corp. Long-Term Disability Plan, 326 F.3d 914, 919 (7th Cir. 2003); Kennedy v. Lilly Extended Disability Plan, 856 F.3d 1136, 1138–40 (7th Cir. 2017).
Build credibility through consistency. Keep a symptom journal, gather statements from coworkers, family, and friends describing changes they have observed, and make sure your medical records reflect the same complaints over time. Consistent, long-term treatment is persuasive evidence that symptoms are real.
Answer the insurer’s file reviewers
Insurers often rely on doctors who review records without ever examining you. The Seventh Circuit permits this. Mote v. Aetna Life Ins. Co., 502 F.3d 601, 607–08 (7th Cir. 2007); Davis v. Unum Life Ins. Co. of Am., 444 F.3d 569, 577 (7th Cir. 2006). But a file review is only as strong as its reasoning. Have your own doctors respond point by point, correcting misread records and explaining why an in-person examination deserves more weight. A reviewer’s credibility judgments made without seeing the claimant can undercut a denial. Kennedy, 856 F.3d at 1139.
For disability claims filed after April 1, 2018, the insurer must give you any new evidence or new rationale it develops during the appeal and a reasonable chance to respond before it decides. 29 C.F.R. § 2560.503-1(h)(4)(i)–(ii). Use that opportunity every time.
Use Social Security and the insurer’s conflict
If you have been approved for Social Security disability benefits, submit the award and, ideally, the full SSA file. An SSA award does not bind the insurer, but an insurer that encouraged you to apply, took an offset for the benefits, and then ignored the finding invites a court’s skepticism. Metro. Life Ins. Co. v. Glenn, 554 U.S. 105, 118 (2008); Holmstrom, 615 F.3d at 773.
That same case holds that an insurer that both decides and pays claims has a conflict of interest the court must weigh. Glenn, 554 U.S. at 117. The Seventh Circuit allows targeted discovery into that conflict, such as the insurer’s history with particular reviewers. Dennison v. MONY Life Ret. Income Sec. Plan, 710 F.3d 741, 746–47 (7th Cir. 2013).
A quick checklist
1. Request the claim file and the full policy.
2. Calendar the appeal deadline and the policy’s lawsuit deadline.
3. Obtain detailed treating-physician narratives focused on function.
4. Add objective support: testing, a functional capacity evaluation, a vocational report.
5. Submit lay statements and your SSA file.
6. Rebut every file review and respond to any new evidence.
An ERISA appeal is your one real chance to shape the record. Working with an experienced ERISA attorney before you submit it can make the difference between a denial that stands and one a court will reverse.
This article provides general information, not legal advice
