You’ve been collecting long-term disability benefits for 23 months when the letter arrives. Your chronic back pain, diagnosed after a warehouse injury, keeps you from standing more than 20 minutes at a time, but fortunately, the monthly checks cover your mortgage and other expenses. Now your insurer sends you a denial notice, effective immediately. After two years of approved claims, they now argue that you should be able to work again.

Long-term disability insurance usually starts after short-term disability ends or after a waiting period of 90 to 180 days. Coverage can last anywhere from two to ten years, or until you reach age 65, depending on your policy terms. Most people assume approval means permanent support, unaware that insurers build review triggers into contracts.

For the first two years, most policies define disability as the inability to perform your “own occupation,” which is the job you held when you became disabled. After 24 months, many contracts switch to an “any occupation” standard, which lets them deny benefits if they believe you can perform any job that matches your education, training, age, and experience, even if it pays far less than your previous role. 

As you can imagine, this catches a lot of people off guard. Fortunately, you have recourse, and a Michigan workers’ compensation lawyer can help.

Common Reasons for Denial After Two Years

Insurers don’t deny benefits at the two-year mark by coincidence. This is when policy terms shift in their favor, and they’ve had 24 months to build a case against you. The reasons for denial range from stricter definitions of disability to alleged ‘failure to cooperate.’ Knowing what they are can give you a head start on protecting your access to benefits.

Reason #1: Change in Disability Definition

The switch from “own occupation” to “any occupation” drives most denials at the 24-month mark. During the first two years, your insurer only needs to confirm you can’t perform the duties of your specific job. If you worked as a surgeon and can’t operate due to hand tremors, you qualify under “own occupation” even if you could teach or consult. 

After 24 months, the insurer will evaluate whether you can work in any job that’s compatible with your background. A 58-year-old former construction foreman with a high school diploma and severe arthritis can’t be matched to a desk job requiring a college degree, but insurers push the boundaries. They’ll suggest sedentary roles like data entry, phone customer service, or inventory tracking: jobs that exist in the labor market but may not reflect your actual capabilities or pay anywhere near your former salary.

Vocational experts hired by insurers comb through databases to find these positions. They don’t assess whether you can actually get hired or whether employers would accommodate your limitations. They simply prove jobs exist on paper, which satisfies the policy’s “any occupation” language.

Reason #2: Independent Medical Exams (IME)

Insurers schedule IMEs to obtain a second medical opinion, but the doctors they choose rarely side with claimants. These exams last 15 to 30 minutes, which is far shorter than appointments with your treating physician. The IME doctor reviews your file beforehand, performs a brief physical assessment, and submits a report.

These reports frequently conclude you’ve improved enough to return to work, even when your own doctor disagrees. The insurer pays the IME doctor’s fee, creating an inherent bias. Your treating physician has no financial stake in the outcome and has tracked your symptoms, treatment responses, and daily functioning over time. Yet insurers give IME opinions equal or greater weight.

Reason #3: Surveillance Footage

Private investigators have been known to follow claimants for days or even weeks, filming activities that appear inconsistent with disability claims. If you claim you can’t lift more than ten pounds but surveillance catches you carrying grocery bags or playing with your kids in the yard, the insurer will use that footage to argue fraud or exaggeration.

This tactic ignores context. Chronic pain fluctuates: you might have one decent day after weeks of severe symptoms, but the investigator only captures that single afternoon. Lifting a grandchild for 30 seconds doesn’t mean you can stock shelves for eight hours. Insurers present these clips without explaining that activities were brief, painful, or followed by days of increased symptoms.

Reason #4: Earnings Threshold

Policies contain offset provisions tied to income. If you return to part-time work and earn a certain percentage of your pre-disability wages (for example, 60% in some policies), benefits stop entirely. This threshold varies by contract, but insurers monitor tax records and Social Security earnings reports. Even occasional freelance work or consulting income can trigger termination if it crosses the policy limit within a calendar year.

The calculation doesn’t account for job sustainability. You might manage 15 hours per week for three months before your condition worsens and forces you to quit. The insurer sees only the earnings during that quarter and terminates benefits, leaving you with no income when the work becomes unsustainable.

Reason #5: Failure to Cooperate

Missing a scheduled IME, submitting incomplete paperwork, or ignoring requests for updated medical records gives insurers grounds to deny benefits for non-compliance. Policies require claimants to provide proof of ongoing disability: if you skip follow-up appointments with your doctor or don’t respond to insurer correspondence within stated deadlines, the company can argue you abandoned your claim.

The Two-Year Review Process

Insurance providers begin preparing for the 24-month review long before your benefits hit the two-year mark. This review follows a series of steps intended to create a case for denial, although they’ll make it sound objective.

File Review for Red Flags

Claims adjusters will pull your entire file and look for inconsistencies. For example:

• They’ll compare medical records from month six to month 18, searching for improvement notes your doctor might have documented. A single comment like “patient reports reduced pain this week” gets highlighted, even if the next visit shows that symptoms returned. 
• They scan for gaps in treatment, such as times when you didn’t see your specialist or skipped physical therapy. These gaps get framed as evidence that you no longer need medical care, even if there were financial constraints or appointment availability issues.

Adjusters will also cross-reference your file with pharmacy records. If you stopped filling prescriptions for pain medication, they’ll argue you’ve recovered. If you continue filling them, they question why treatment hasn’t restored function. It’s all about identifying ammunition for denial.

Vocational Analysis

Insurers may hire vocational rehabilitation consultants to match your residual abilities to available jobs. These consultants receive your medical restrictions (can sit six hours, lift ten pounds, no overhead reaching) and search labor market databases for positions within those limits. Then they’ll produce reports listing job titles, average wages, and required qualifications.

The jobs listed are real positions that exist somewhere, but the analysis stops there. It doesn’t verify openings in your geographic area, assess whether employers would hire someone with documented medical limitations, or account for the reality that sedentary jobs attract hundreds of applicants. The insurer only needs to prove jobs exist that you could theoretically perform, not that you’d get hired or sustain employment.

Functional Capacity Evaluations

Some policies allow insurers to require functional capacity evaluations (FCE) before the 24-month deadline. These tests measure your ability to lift, carry, stand, walk, and perform job-related tasks over several hours. Physical therapists administer the tests in clinical settings and push you to maximum exertion levels.

The results rarely capture real-world limitations. Chronic conditions like fibromyalgia or multiple sclerosis cause post-exertional crashes: you might complete the FCE tasks during the evaluation, but spend the next three days bedridden. The test also measures what you can do once, not what you can sustain daily for weeks or months. However, insurers will use passing scores as proof that you’re capable of full-time work.

ERISA Considerations for Employer Plans

If your policy comes through an employer-sponsored group plan, it falls under the Employee Retirement Income Security Act (ERISA). Federal courts oversee these cases, which limits your appeal options and shortens deadlines. ERISA requires insurers to provide full claim files and give claimants 180 days to appeal denials. However, courts apply a deferential standard of review, meaning judges often uphold insurer decisions unless they’re arbitrary or capricious.

ERISA also caps damages. You can recover unpaid benefits, but not punitive damages or compensation for emotional distress, which reduces insurers’ financial risk when denying legitimate claims.

Michigan-Specific Protections for Claimants

Michigan law requires insurers to handle claims in good faith and provide clear explanations for denials; they must specify the policy provisions relied upon and the medical evidence considered. If your insurer violates these requirements, you can file complaints with the Department of Insurance and Financial Services. At LegalGenius, we handle appeals and litigation for claimants facing wrongful denials, so if it happens to you, we can help.

How Long Do You Have to Respond to a Denial in Michigan?

Insurers normally send termination notices 30 to 60 days before benefits stop, which can give you time to gather evidence for an appeal. Then, once benefits end, you have 180 days to file an administrative appeal under most policies. Missing this deadline forfeits your right to challenge the denial in court. 

The insurer, which reviews your appeal internally, usually takes 45 to 90 days to issue a final decision. If they uphold the denial, you can file a lawsuit, but it’s important to note that courts only consider evidence submitted during the administrative appeal: you can’t introduce new medical records or expert opinions later.

How to Appeal a Long-Term Disability Benefits Denial

To launch an appeal, you’ll want to address every reason for the denial and submit evidence contradicting the insurer’s conclusion. Here’s how you can get started.

Gather Strong Medical Evidence

Your treating physician’s opinion carries the most weight, so request a letter that addresses the denial reasons. If the insurer claims you’ve improved, your doctor should explain why your condition remains disabling and reference objective findings like test results, imaging studies, or observed limitations during recent exams. Generic letters stating “patient is disabled” won’t overcome an IME report or vocational analysis.

Functional capacity assessments from your own medical team can also counter insurer-ordered evaluations. These assessments document what you can and can’t do in real-world conditions over time. They should list how long you can sit or stand, how much weight you can lift, and any cognitive limitations if applicable. 

You can support your medical team’s findings with daily activity journals. Record pain levels, medications taken, activities attempted, and how those activities affected you afterward. If insurer surveillance caught you grocery shopping, your journal entry for that day should note you shopped for 20 minutes, needed help loading bags, and spent the rest of the day in bed with increased pain. These journals establish context missing from edited video clips.

Hire a Michigan Workers’ Comp Attorney

ERISA claims and LTD appeals involve federal regulations that most claimants can’t handle without help. An experienced workers’ compensation lawyer can prepare an appeal that’s compelling, includes persuasive evidence, and directly refutes the insurer’s claims. They’re also aware of the limited record rule (federal courts only review evidence submitted during the administrative appeal), so they’ll make sure they build a complete record.

Michigan firms that handle LTD litigation, such as LegalGenius, know both federal ERISA procedures and state insurance regulations. They can identify when your insurer violated Michigan’s good faith handling requirements or failed to provide adequate denial explanations as per state law. Local attorneys also have established relationships with medical professionals who can review your file and provide supporting opinions.

Request the Full Administrative Record

ERISA requires insurers to provide complete claim files upon request. This record includes every document they reviewed when denying your claim: medical records, IME reports, vocational analyses, surveillance footage, internal notes, and correspondence. Review this file carefully, as insurers sometimes make decisions based on incomplete medical records or outdated information. If key documents are missing, you can submit them during the appeal and argue the denial was based on an insufficient record.

The administrative record also reveals the insurer’s decision-making approach. Internal emails might show adjusters were pressured to meet denial quotas. Notes might indicate they ignored favorable medical evidence. These procedural violations can support your appeal and, if necessary, your lawsuit.

Consider Federal Litigation

If the insurer denies your appeal, you can file a lawsuit in federal court. ERISA cases don’t go to juries: judges review the administrative record and determine if the denial was reasonable. Policies with discretionary clauses receive more deferential review, making them harder to overturn, but not impossible.

Even with these limitations, litigation creates settlement pressure. The insurance provider will be saddled with attorney fees, court costs, and the risk of adverse precedent if they lose. Many cases settle during litigation for partial benefits, lump sum payments, or reinstatement with back pay. Your attorney can negotiate these settlements while preparing for trial.

Legal Tip: Michigan’s Department of Insurance and Financial Services accepts complaints about insurer practices. Filing a complaint won’t directly reverse your denial, but it creates a regulatory record and may trigger an investigation if multiple claimants report similar problems with the same company. The department can also clarify when your insurer violated state regulations.

Denial Prevention Tips

Preventing denial at the two-year mark can start before you ever file a claim. Understanding your policy terms and maintaining thorough documentation gives you leverage when insurers begin their review.

• Read Your Policy Carefully: If you have an employer-sponsored plan, request a copy of the full policy document from Human Resources, as the summary plan description doesn’t include all terms. If you bought an individual policy, review your contract. Look for the disability definition change at 24 months: some policies maintain “own occupation” coverage for the full benefit period, while others switch to “any occupation” immediately. Individual policies labeled “true own occupation” cost more but provide stronger protection.
• Document Everything: Keep records of every medical appointment, treatment, and symptom from the day you become disabled. Save copies of all paperwork you submit to your insurer and note the date you sent it. Store denial letters, approval notices, and correspondence in a dedicated file.
• Track New Symptoms: If your condition worsens or new symptoms develop, get them documented immediately by your physician. Gaps in medical records give insurers ammunition for denial.
• Schedule Annual Policy Reviews: For individual policies, meet with an insurance advisor to catch coverage gaps. Confirm your benefit amount still replaces an adequate income if your salary has increased. For employer plans, check your coverage each open enrollment period and verify your occupation classification matches your current job duties, as a job title change can affect how insurers evaluate disability.

Taking these steps won’t guarantee approval, but they reduce the evidence insurers can use against you when the 24-month review arrives.

Was Your Long-Term Disability Denied? Call Us!

Insurers target the 24-month milestone because policy language shifts in their favor, and they’ve spent two years collecting evidence to justify termination. The change from “own occupation” to “any occupation” lets them argue you can work jobs that exist only on paper. IME doctors spend 20 minutes examining you and conclude you’ve recovered. Surveillance captures you on your best day and ignores the pain that follows. Vocational reports list outdated job titles that no longer reflect the current labor market.

These tactics succeed when claimants don’t recognize them as strategies rather than objective assessments. Unfortunately, the 180-day appeal window doesn’t allow time to figure out ERISA regulations, gather medical evidence, and put together an appeal that can stand up in court.

At LegalGenius, we represent Michigan claimants facing wrongful denials at the two-year mark. We can handle both the administrative appeal and federal litigation if needed, and will use our experience and resources to prepare the strongest possible argument. To schedule a free consultation, complete our Ask the Genius™ form on our website, and an attorney will contact you within five minutes. We look forward to being of service!

Attorney Jeffrey Perlman

Attorney Jeffrey Perlamn is the managing partner at LegalGenius, PLLC. He has helped Metro Detroit accident victims recover the compensation they deserve for over 35 years. He believes everyone should have access to justice and the legal system, which is why Attorney Perlman spends his time outside of the courtroom writing informational blogs on the LegalGenius website that are accessible to all.