ERISA and Long-Term Disability Intake: How to Qualify Benefit Denial Cases on the First Call

Insurance companies deny more than 60 percent of initial long-term disability claims. The callers who reach your firm already know they have a real disability. What they do not know is that they may be three weeks from losing the legal right to fight back.

ERISA intake is not standard personal injury intake. The medical story matters far less than the procedural timeline. Whoever picks up the phone at your firm needs to lead with jurisdiction and deadlines — not symptoms and treatment history. This guide covers every qualifying question that matters, what the answers tell you, and how to structure the call so nothing slips through.

Why ERISA Intake Is Different from Every Other Practice Area

Most intake calls are fact-driven. What happened, who was at fault, what are the injuries. The caller’s story is the roadmap.

ERISA intake is document-driven and process-driven. The condition itself is almost secondary. What determines viability is:

• Was the coverage through an employer-sponsored plan?
• What stage is the administrative appeal process at?
• When did the most recent denial letter arrive?
• Has the caller done anything that could compromise the administrative record?

A caller with a severe, well-documented disability and an expired appeal window has no viable ERISA case. A caller with a contested diagnosis and a denial letter that arrived yesterday has a case worth developing immediately.

This is the fundamental shift your intake team needs to make before answering any LTD call.

The 6 Qualifying Questions for Every ERISA and LTD Call

1. Was the disability insurance provided through an employer?

This is the ERISA threshold question. ERISA covers employer-sponsored benefit plans in the private sector. It does not cover individual policies purchased from an insurer, church plans, government employee plans (federal, state, or municipal), or plans covering only a solo business owner.

If the policy was purchased independently, this is not an ERISA case. It may be a state law breach-of-contract or bad faith claim, which requires different analysis and often different attorneys.

What to ask: “Was this disability coverage part of your employee benefits package at work, or did you purchase it separately on your own?”

What it tells you: ERISA jurisdiction yes or no. If the answer is no, flag it immediately and route it as a non-ERISA insurance dispute. Do not spend the next ten minutes developing a case your firm cannot take.

2. What has the insurance company done so far?

LTD claims move through a fixed sequence: initial application, initial denial, first-level appeal, second-level appeal (if the plan allows one), then federal litigation. Where the caller sits in this sequence determines what your firm can actually do.

The most valuable stage to enter is before or during the first appeal. The administrative record is still being built. Everything submitted during the appeal process becomes the evidentiary record in any future lawsuit. After the administrative record closes, courts reviewing ERISA claims are generally limited to what is already in that record.

What to ask: “Have you received a written denial letter from the insurance company? How many? Have you filed any appeals yet, and if so, have those been denied too?”

What it tells you: Which stage of the process you are entering, and how much attorney involvement is still possible before litigation becomes the only option.

3. When exactly did you receive the most recent denial letter?

This is the most time-critical question in the entire call. Under ERISA regulations, claimants generally have 180 days from a denial to file an administrative appeal. Some plans shorten this window. Courts do not routinely excuse missed ERISA appeal deadlines — the window closes and it stays closed.

If a claimant misses the appeal deadline, the administrative record is sealed. The right to add new medical evidence, new functional capacity evaluations, or new treating physician opinions is gone. Any future lawsuit is litigated on a closed record with limited judicial review.

What to ask: “Can you tell me the date printed on the denial letter itself — not when you received it in the mail, but the date the insurance company put on it?”

What it tells you: How much time remains. If the denial is more than 90 days old, treat it as urgent. If it is over 150 days old, get it in front of an attorney today. If the 180-day window has already passed, you need to understand the full timeline before determining whether any exceptions apply.

4. What is the diagnosis, and has the treating physician documented it?

ERISA denials frequently come down to the quality of medical documentation in the administrative record. Insurance companies classify certain conditions as subjective — fibromyalgia, chronic fatigue, depression, anxiety, chronic pain — and apply heightened scrutiny. The medical evidence must use the specific functional limitation language the plan requires to establish disability.

The diagnosis matters for case valuation. The documentation matters for case viability. A severe diagnosis with thin physician records is harder to win than a moderate diagnosis with extensive functional capacity evidence.

What to ask: “What is the medical condition that prevents you from working? Has your treating doctor been actively involved in the claim — providing records and written support to the insurance company?”

What it tells you: Whether the medical foundation exists to build a credible administrative record on appeal. If the treating physician has not been engaged, that is fixable — but only if there is time left on the appeal clock. See our guide on training intake coordinators to gather complete case information for related documentation best practices.

5. Does the plan define disability as own occupation or any occupation?

This distinction determines the standard of proof and is often the hinge point of the entire case.

Own occupation: The claimant is disabled from performing the duties of their specific job. A neurosurgeon who can no longer perform surgery but could theoretically work a desk job is still disabled under this definition.

Any occupation: The claimant must be unable to perform any gainful employment. The same neurosurgeon who could work as a medical consultant or educator would not qualify.

Most group LTD plans transition from own occupation to any occupation after 24 months. This transition point is where a significant number of approved claims get terminated — the claimant was qualifying under the own-occupation standard, then re-evaluated under the far more demanding any-occupation standard.

What to ask: “Do you know whether your policy covers inability to do your specific job, or inability to do any type of work at all?”

What it tells you: The standard of proof, and whether the caller may have been caught at the own-to-any transition. This affects both strategy and case valuation.

6. Which insurance company denied the claim, and does the caller have the Summary Plan Description?

Certain carriers — Unum, MetLife, Hartford, Cigna, Lincoln Financial, Prudential — are known for systematic denial practices. Identifying the carrier immediately signals the likely denial rationale and what arguments have traction in litigation against that specific insurer.

The Summary Plan Description (SPD) is the foundational document. It defines disability, sets the appeal timeline, and governs the claims process. Courts have held that insurers cannot enforce plan provisions not disclosed in the SPD. Without it, your attorneys are working without the rulebook.

What to ask: “Which insurance company sent the denial? And do you have a copy of the Summary Plan Description — the booklet that explains your employee benefits?”

What it tells you: Carrier-specific litigation intelligence and whether your attorneys will need to obtain the SPD through discovery or a direct request to the employer’s HR department.

What Disqualifies an ERISA and LTD Case

Not every denial letter is a viable case. Here is what disqualifies at intake:

The policy is not ERISA-governed. Individual, church, and government plans are outside ERISA. These callers may have state-law claims, but they need a different referral path.

The appeal deadline has expired. Courts generally will not extend the administrative appeal window. If the 180 days — or whatever the plan specifies — has passed without an appeal filed, the administrative record is closed.

The claimant already filed a federal lawsuit without exhausting administrative remedies. ERISA requires exhaustion of internal appeals before litigation. A premature lawsuit can be dismissed, though courts sometimes allow reinstatement of the administrative process. This needs immediate attorney review.

A valid plan exclusion applies. Many LTD plans exclude pre-existing conditions for the first 12 to 24 months of coverage. If the disability relates to a condition actively treated before coverage began, the insurer may have a legitimate exclusion.

The claimant left the job before filing. Active employment status at the time of disability onset is required under most plans. A claimant who voluntarily resigned and then filed may be outside plan coverage.

Red Flags That Complicate an Otherwise Viable Case

These do not disqualify a case, but they signal complications your attorneys need before accepting the file:

• The claimant is also receiving or applying for Social Security Disability Income (SSDI). ERISA plans typically offset LTD benefits by SSDI amounts, which affects settlement structure and case valuation.
• There is a concurrent workers compensation claim from the same condition.
• The employer changed LTD carriers during the disability period — which carrier’s plan governs can be disputed.
• The claimant relocated to a different federal circuit since the claim began. ERISA case law varies significantly by circuit, and the applicable precedent may shift.
• The claimant retained and then fired a prior attorney. Understand why before the file is accepted.

Document every one of these on the intake form. Do not try to resolve them on the call. That is the attorney’s job.

Handling the Caller Who Has Already Been Denied Twice

A second-level denial is the end of the administrative road under most ERISA plans. The only remaining option is federal litigation.

The timeline for filing suit is usually set by the plan itself, not ERISA statute — typically between one and three years from the final denial, though some plans impose shorter windows. Courts have generally upheld plan-imposed limitations periods, including periods as short as 90 days after the final denial in some circuits.

For callers who have received a second denial:

1. Get the exact date of the second denial letter.
2. Ask whether they have the plan document showing the limitations period for lawsuits.
3. Flag the file as urgent and route it to an attorney that day.
4. Make no representations about viability on the call.

The caller who has been denied twice and is calling a law firm has done everything procedurally right. They deserve to know they are not out of options — but the honest answer is that what comes next is an attorney conversation, not an intake conversation. Learn more about how intake technology helps law firms triage time-sensitive cases faster.

The ERISA Intake Call Flow

Here is a reliable call structure for ERISA and LTD intakes:

Opening (30 seconds): Build rapport and frame the call. “Thank you for calling. I want to make sure I understand your situation completely so I can connect you with the right person. Can you start by telling me what happened with your disability claim?”

Stage check (2 minutes): Establish where they are in the process. First denial, first appeal, second denial, or still in the initial claim stage.

Jurisdiction check (1 minute): Confirm this is an employer-sponsored plan, not an individual policy, church plan, or government plan.

Deadline check (1 minute): Get the exact date on any denial letter. Calculate days remaining in the appeal window.

Medical snapshot (2 minutes): Diagnosis, treating physician involvement, quality of documentation.

Plan details (1 minute): Own occupation versus any occupation definition. Carrier name.

Close (30 seconds): Clear next step and protective instruction.

Total call: 8 to 10 minutes. Not more. ERISA intakes are not complex conversations — they are precise ones. The goal is to extract the seven or eight facts that determine viability, not to build a full case narrative on the phone.

The Intake Form: What to Capture on Every ERISA Call

Every ERISA and LTD intake record should document:

• Full name, phone, email, current mailing address
• Employer name and state
• Insurance carrier and policy number (if known)
• Plan type: employer-sponsored group LTD (yes or no)
• Date disability began
• Date coverage was effective
• Diagnosis as stated by treating physician
• Date(s) of denial letters
• Whether any appeals have been filed and when
• Whether any lawsuit has been filed
• SSDI application status
• Whether caller has the Summary Plan Description
• Urgency flag: days remaining on appeal window
• Red flags noted (concurrent WC claim, prior attorney, plan change, etc.)

The one field that cannot be missing is the denial letter date. That single date determines how much time your attorneys have to act. See how eNZeTi helps law firms track intake metrics that actually matter to catch cases like these before the clock runs out.

The Most Common Intake Mistake in ERISA Cases

Spending the first fifteen minutes of the call on the medical history before establishing the procedural timeline.

Intake teams trained on personal injury cases are conditioned to lead with empathy and gather the injury narrative first. That discipline works for PI. In ERISA, the medical story is secondary to the process. A caller with an undeniable disability and a denial letter that expired two weeks ago has no viable ERISA case under standard analysis.

Lead with the procedural questions. Establish jurisdiction. Establish the timeline. Get to the medical facts only after you know the case has a viable foundation. This protects the caller from building hope around a case that cannot move forward, and it protects your firm from investing development time in files that cannot be signed.

How to Close Every ERISA Intake Call

Regardless of where the caller is in the process, close every LTD call with a clear instruction and a concrete next step:

“Based on what you’ve told me, this is something our attorneys need to review. I’m making sure this reaches someone today. Because of the deadlines involved in disability claims, we treat every intake as time-sensitive. You’ll hear from us within [your SLA]. In the meantime, please don’t sign anything the insurance company sends you, don’t respond to any written requests without speaking to an attorney first, and don’t miss any deadlines they’ve set.”

That last instruction protects the caller from two common self-inflicted case killers: signing settlements under pressure and responding to insurance company documentation requests in ways that hurt the appeal record. Giving them that guidance is a genuine service regardless of whether your firm ultimately takes the case.

See how eNZeTi works in a real law firm — Book a Free Call Analysis at enzeti.com