- Long-term disability is based on function, not just diagnosis. Insurers care most about whether your condition prevents you from doing your job, not just whether you have a medical issue.
- Your policy’s definition of disability is the most important factor. Whether it’s own-occupation, any-occupation, or modified own-occupation determines whether your claim qualifies.
- Insurers require strong medical documentation. A diagnosis alone isn’t enough—your condition must be well-documented, consistent, and supported by objective evidence whenever possible.
- Claims often fail due to gaps in evidence or treatment. Common denial reasons include missing documentation, inconsistent symptoms, treatment noncompliance, or lack of objective proof.
- The “work test” is crucial. Insurers compare your medical limitations to your job duties, work environment, and schedule to decide if you can still work.
- Mental health claims are frequently undervalued. Insurers often require more detailed documentation because these conditions can be harder to prove objectively.
- A denial isn’t the end—appeals can succeed. If your claim is denied, you should review the denial reasons, gather stronger evidence, file an appeal quickly, and consider legal help if needed.
Long-term disability (LTD) benefits can be a lifeline when a serious illness or injury prevents you from working. But even when you think your situation clearly qualifies, insurers still deny claims every day. The frustrating part is that the rules aren’t always obvious, and the reasons for denial can feel vague or unfair.
This guide breaks down exactly what qualifies for long-term disability, what insurers look for when reviewing claims, and the most common reasons claims fail. Whether you’re applying for benefits for the first time or trying to appeal a denial, understanding how insurers evaluate claims is the first step to getting the outcome you deserve.
What Counts as “Long Term Disability” in the First Place?
Long-term disability is insurance that replaces a portion of your income if you can’t work for an extended period due to illness or injury.
But it’s not just about being “sick” or “injured.” Insurers define disability in specific ways, and your claim must match their definition.
How long does “long term” actually mean?
Typically, long term disability benefits start after short-term disability ends, usually after 90 days. Some policies start sooner or later, but the key point is that LTD is meant for long-term or permanent inability to work.
What do insurers usually cover?
Most LTD policies cover conditions like:
- Severe injuries (car accidents, workplace injuries)
- Chronic illnesses (autoimmune diseases, chronic pain disorders)
- Mental health conditions (depression, anxiety, PTSD)
- Cancer and its treatment effects
- Neurological disorders (multiple sclerosis, Parkinson’s)
- Serious heart conditions
But the condition alone isn’t enough. Your ability to work is what matters.
What Qualifies for Long Term Disability: The Insurer’s Checklist
When an insurer reviews your claim, they’re not just evaluating your medical condition. They’re looking for proof that your condition prevents you from performing your job duties.
Here’s what they look for:
1. Your diagnosis is real and documented
Insurers want clear medical proof. A diagnosis alone isn’t enough — they want consistent documentation from your doctors.
2. Your symptoms are severe enough to limit your work
Insurers compare your symptoms to your job requirements. If your condition doesn’t clearly limit your ability to perform tasks, your claim may be denied.
3. Your treatment is ongoing and appropriate
Insurers look for evidence that you are getting appropriate care. If you’re not seeing specialists, following treatment plans, or taking prescribed medications, the insurer may argue your condition is manageable.
4. Your limitations are consistent over time
If your symptoms vary or improve temporarily, insurers may argue that you can work some days. They’re looking for ongoing limitations.
5. Your condition is supported by objective medical evidence
Objective evidence includes things like:
- MRIs, X-rays, CT scans
- Blood tests
- Physical therapy evaluations
- Surgical reports
- Neuropsychological testing
Subjective complaints like “I feel pain” matter, but insurers often want objective proof.
How Insurers Define “Disability” (And Why It Matters)
Your policy’s definition of disability is the most important part of your claim. If you don’t meet that definition, your claim can be denied even if you’re seriously ill.
What are the most common disability definitions?
Most policies fall into one of these categories:
Own-Occupation Definition
You’re considered disabled if you can’t perform your own job.
Pros: This is the most generous definition.
Cons: It can be harder to qualify if you can do another job.
Any-Occupation Definition
You’re considered disabled only if you can’t perform any job.
Pros: More restrictive for claimants.
Cons: Often leads to denials if the insurer believes you can work in another role.
Modified Own-Occupation
You qualify for a period (often 2 years) if you can’t do your own job, then it switches to any occupation.
Pros: Offers some protection early on.
Cons: You may lose benefits later if you could do a different job.
What Qualifies for Long Term Disability: The “Work Test”
Many people think LTD is based only on medical evidence. In reality, insurers use a “work test” to evaluate your ability to perform job tasks.
What is a work test?
A work test compares your:
- Job duties
- Work environment
- Physical demands
- Cognitive demands
- Travel requirements
- Shift length and schedule
to your medical limitations.
What kind of job documentation do insurers want?
Insurers may ask for:
- Job descriptions
- Performance evaluations
- Employer statements
- Occupational analyses
- Wage information
The more detailed the documentation, the stronger your claim.
Why Claims Fail: The Top Reasons Insurers Deny LTD Benefits
Even when someone is clearly disabled, claims can fail for reasons that have nothing to do with the severity of the illness. Here are the most common reasons:
1. Insufficient medical evidence
This is the number one reason claims fail. Insurers need proof, not just your word.
2. Lack of objective evidence
Many conditions (like chronic pain or fatigue) are difficult to prove objectively, and insurers often use this as a reason to deny.
3. Your job duties don’t match your limitations
If the insurer believes you can still perform your job or another job, they may deny your claim.
4. Treatment gaps or noncompliance
If you stop treatment or fail to follow your doctor’s recommendations, the insurer may claim you are not truly disabled.
5. Missing deadlines
LTD policies have strict timelines for filing claims and submitting documentation. Missing a deadline can lead to denial.
6. Pre-existing condition exclusions
Some policies exclude or limit coverage for pre-existing conditions.
7. Mental health limitations are undervalued
Insurers often treat mental health claims with more skepticism, especially if objective evidence is limited.
What Qualifies for Long Term Disability: Common Conditions That Qualify (and Why)
Here are some conditions that often qualify for LTD, and what insurers look for in each case.
Chronic pain conditions
Examples: fibromyalgia, chronic back pain, complex regional pain syndrome (CRPS)
What insurers want to see:
- Consistent medical documentation
- Objective testing (MRIs, nerve studies)
- Treatment records (physical therapy, pain management)
Autoimmune diseases
Examples: lupus, rheumatoid arthritis, multiple sclerosis
What insurers want to see:
- Blood tests and lab results
- Specialist notes
- Treatment compliance
Mental health conditions
Examples: depression, anxiety, PTSD, bipolar disorder
What insurers want to see:
- Therapy records
- Psychiatric evaluations
- Medication compliance
- Functional limitations (ability to concentrate, handle stress)
Neurological conditions
Examples: MS, Parkinson’s, traumatic brain injury
What insurers want to see:
- Neurologist reports
- Imaging results
- Cognitive testing
- Physical limitations
What Insurers Look for During the Claim Review Process
The “First Impression” Stage
When you first submit your claim, the insurer decides whether to accept or deny based on the initial documentation.
If the evidence isn’t strong, your claim may be denied quickly.
The “Investigation” Stage
If your claim moves forward, insurers may:
- Review your medical records
- Request additional information
- Schedule an Independent Medical Examination (IME)
- Check your social media and public activities
- Contact your employer
The “Decision” Stage
Insurers decide based on:
- Medical evidence
- Job requirements
- Policy definition of disability
- Consistency of symptoms
- Treatment compliance
How to Make Sure Your Claim Meets the Standard
Here are practical steps to increase your chances of approval.
1. Document everything
Keep a record of:
- Symptoms
- Doctor visits
- Medications
- Treatments
- Side effects
- Daily limitations
2. Get strong medical support
Ask your doctor to:
- Provide detailed notes
- Explain functional limitations
- Connect your condition to your inability to work
3. Follow treatment plans
Insurers look for compliance. If you stop treatment, it can weaken your claim.
4. Be consistent
If your symptoms fluctuate, keep a daily journal. Inconsistency is a common reason for denial.
5. Get job documentation
Your employer can provide:
- Job description
- Work schedule
- Performance expectations
- Any accommodations you tried
6. Be careful with social media
Insurers sometimes review social media posts to look for evidence that you’re active or able to work.
What Qualifies for Long Term Disability: What You Should Avoid
To prevent common mistakes, avoid these pitfalls:
- Missing deadlines
- Submitting incomplete medical records
- Not following treatment
- Providing vague symptom descriptions
- Underestimating the importance of job documentation
- Ignoring mental health symptoms
- Assuming the insurer will “see” your disability without proof
What to Do If Your Claim Is Denied
A denial isn’t the end. Many claims are approved on appeal.
What to do next:
- Request the denial letter in writing: This letter will outline the reason for denial and the appeals process.
- Review the policy definition of disability: This is crucial. You may qualify under a different definition than you think.
- Gather more evidence: Add more medical records, test results, and functional reports.
- File an appeal promptly: Most policies have strict deadlines.
- Consider getting legal help: An attorney specializing in LTD claims can improve your chances, especially if the insurer is using bad-faith tactics.
How a Lawyer Can Help With LTD Claims
Lawyers don’t just “argue” for you. They help build the strongest possible claim.
What a lawyer can do:
- Review your policy
- Identify weaknesses in the insurer’s denial
- Gather medical and job evidence
- Help you navigate appeals
- Communicate with the insurer on your behalf
- Represent you if the case goes to court
The Bottom Line
Qualifying for long-term disability isn’t just about having a serious illness or injury. It’s about proving that your condition prevents you from performing your job according to the exact terms of your policy. Insurers evaluate claims based on medical documentation, consistent symptoms, treatment compliance, and how your limitations match your job duties. Without clear evidence, even legitimate claims can be denied.
If your claim is denied, it doesn’t mean you’re out of options. Many claims are approved on appeal when additional evidence is provided or when the policy’s definition of disability is clearly explained. The key is to stay organized, follow your treatment plan, document everything, and seek help if needed. With the right approach, you can build a stronger case and improve your chances of getting the benefits you deserve.
