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When to Start the Claims Process
The most common mistake employees make with disability insurance claims is waiting too long to file. Many people assume they should wait until they are certain they will be out of work for an extended period. In reality, you should notify your employer and the insurance carrier as soon as you know your condition will prevent you from working beyond a few days.
Most disability policies have specific notification requirements. Short-term disability claims typically require notification within 15-30 days of the disability onset. Long-term disability claims must be filed during or shortly after the elimination period. Missing these deadlines can delay or jeopardize your claim.
Step 1: Notify Your Employer
Contact your HR department or benefits administrator to report your disability and request the necessary claim forms. Your employer is required to provide you with information about your disability benefits, including how to file a claim, what documentation is needed, and the expected timeline.
Simultaneously, if your condition qualifies, file for FMLA leave to protect your job for up to 12 weeks. FMLA and disability insurance are separate programs, but they often run concurrently. Learn more about FMLA and disability insurance coordination to understand how these protections work together.
Step 2: Complete the Employee Statement
The carrier will provide a claim form with an employee section that requires your personal information, employment details, a description of your condition and how it prevents you from working, the names and contact information of all treating physicians, and information about any other income sources or disability benefits you may receive (such as workers' compensation or Social Security).
Be thorough and specific when describing how your condition affects your ability to work. Instead of writing "back pain prevents me from working," write "herniated disc at L4-L5 causes radiating pain down my left leg that limits my ability to sit for more than 15 minutes, stand for more than 10 minutes, or lift objects over 5 pounds. My job as an accountant requires sitting at a desk for 8 hours per day."
Step 3: Attending Physician Statement
Your treating physician must complete a section of the claim form called the Attending Physician Statement (APS). This is the most critical document in your claim. The APS should include your diagnosis with ICD-10 codes, objective clinical findings (MRI results, lab values, examination findings), functional limitations with specificity (cannot sit more than 20 minutes, cannot lift over 10 pounds, cannot concentrate for extended periods), current treatment plan and prognosis, and an estimated return-to-work date or statement that the disability is indefinite.
Coordinate with your physician before they complete the APS. Ensure they understand your job duties and can specifically address why your condition prevents you from performing those duties. Vague or incomplete APS submissions are the leading cause of initial claim denials.
Step 4: Employer Statement
Your employer completes a section confirming your employment details, job duties, salary, last day worked, and whether you are receiving any other compensation during your absence (such as sick pay or PTO payouts). Review this section if possible to ensure accuracy, as errors in salary reporting or job description can affect your benefit calculation.
Step 5: Review and Decision
Once the carrier receives all documentation, they have 45 days to make an initial decision (under ERISA-governed plans). The carrier may request additional medical records, conduct a phone interview, or arrange an independent medical examination (IME). Cooperate promptly with all requests, as delays can be used to deny or delay your claim.
If approved, the carrier will issue a benefit determination letter specifying your monthly benefit amount, the benefit start date, any offsets (Social Security, workers' compensation), and any conditions for ongoing benefits (such as periodic proof of continuing disability). For more information about how elimination periods affect your coverage, review our guide to understanding elimination periods. Understanding partial disability and returning to work can help you navigate the approval process.
What to Do If Your Claim Is Denied
Denials are not uncommon, and a denial is not the end of the road. Under ERISA plans, you have 180 days to file an internal appeal. The appeal should include a detailed letter addressing each specific reason cited in the denial, additional medical evidence that supports your claim (new test results, specialist opinions, functional capacity evaluations), a letter from your physician directly rebutting the carrier's medical reviewer's conclusions, and any vocational evidence demonstrating that you cannot perform your occupation.
The appeal stage is critically important because, under ERISA, the administrative record is generally "closed" after the appeal. This means that any evidence not submitted during the appeal cannot be introduced if the case proceeds to federal court. Treat the appeal as your trial, not a formality.
If the appeal is denied, you have the right to file a lawsuit in federal court under ERISA Section 502(a)(1)(B). At this stage, consulting with an ERISA disability attorney is strongly recommended, as the legal standards and procedures are highly specialized.
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Written by
Cofounder Hollowtree Solutions & Marketplace. Executive MBA from Columbia Business School and London Business School, former attorney. Entrepreneur, investor, adviser.