Here's where a winning appeal started
Below are six real denials we helped turn around. On the left is the actual denial letter the client received, in the insurer's own words. On the right is the part of our free review that told them what the letter really meant and what a strong appeal would need.
These are based on real appeals we won. Names, addresses, employers, claim numbers, provider names, and dates have been redacted to protect our clients' privacy. The denial language itself is unchanged. Insurers reuse the same wording constantly, so you may recognize your own letter here. We've shown only the analysis, not the full report you'll receive.
"This level of care does not suggest severe impairment in functioning"
The denial letter
The Lincoln National Life Insurance Company · Disability and Life Claims
RE: Short Term Disability (STD) Benefits
Employer Name Inc.
Claim #: 00000000
Dear Client:
The Lincoln National Life Insurance Company is responsible for managing claims for Short Term Disability (STD) benefits under Employer Name Inc.'s Group Disability Plan. We have completed a thorough review of your eligibility for benefits and have determined that benefits are not payable.
The available records reviewed do not support psychiatric restrictions and limitations from December 20, 2025, onward for severity of symptoms resulting in global impairment, related to your diagnoses of condition. With only office visit notes from Dr. Provider and no updated medical records from your psychotherapist, there is limited information provided regarding your ongoing treatment and progress, and there's minimal detail to indicate intensity, duration, or frequency of specific symptoms to corroborate severe functional deficit. Furthermore, it appears your treatment is two to five weeks apart and this level of care does not suggest severe impairment in functioning and can typically be conducted outside of working hours.
Therefore, due to insufficient information, absent office visit notes and medical records, no indication of consistent or ongoing behavioral health treatment, and no evidence to suggest severe impairment in functioning, psychiatric restrictions and limitations are not supported from December 20, 2025, onward.
Based on the medical documentation received in relation to the requirements of your job, you do not meet the definition of disability outlined above. Thus no benefits are payable and we must deny your claim.
This claim determination reflects an evaluation of the claim facts and the Plan provisions. No internal rules, guidelines, protocols, standards or other similar criteria were relied upon in rendering the claim determination.
You may request a review of this denial by writing to the address below. The written request for review must be sent within 30 days from the receipt of this letter and state the reasons you feel your claim should not have been denied.
What our review told her
First, do not miss the March 19, 2026 deadline without notifying Lincoln in writing that you are submitting an appeal. Tell them that you are currently waiting for additional information from your providers and will include that with your appeal as soon as it's available. Normally, insurance companies will give you a little leeway to gather additional material as long as you've told them that you are submitting an appeal. It's okay to call them, but also follow up with a letter or email documenting the conversation to confirm that you told them you were submitting an appeal and were still collecting additional records, etc.
Turning to the denial letter, it says that you stopped working December 20, 2025 due to Generalized Anxiety Disorder (GAD). It sounds like Lincoln only has records from Jessica Van Meter, PMHNP up through January 16, 2026, and does not have any treatment records from your therapist, Adrienne Pastore, LCSW. For the appeal it will be important to make sure that Lincoln has an accurate timeline of the treatment you have received, as well as copies of all your treatment records from December 20, 2025 – present from both Dr. Van Meter and Adrienne Pastore, LCSW.
Lincoln had their in-house nurse review the records from Jessica Van Meter, PMHNP. That review concluded a few things which it will be important for your providers to address directly in the appeal (organized in bullets and highlighted to be a little easier to read):
- there is limited information provided regarding your ongoing treatment and progress
- there's minimal detail to indicate intensity, duration, or frequency of specific symptoms to corroborate severe functional deficit
- your treatment is two to five weeks apart and this level of care does not suggest severe impairment in functioning and can typically be conducted outside of working hours.
Lincoln is basically arguing that if your psychiatric symptoms were disabling, they would expect to see you getting more treatment. It will be important to have your treating providers explain either why Lincoln is wrong about that (and your treatment is in fact more frequent), or why the frequency of your visits are appropriate for your condition even while your condition is severe enough to prevent you from working. Any references they can make to notes in your treatment records, especially about any screening test (such as a GAD-7 screening test for anxiety and/or PHQ-9 screening test for depression or other methods your providers use to gauge severity of symptoms), especially from December – present, regarding the intensity, duration and frequency of your symptoms will make their response stronger. You and your providers should explain how the specific symptoms you have (such as panic attacks) correlate to specific restrictions and limitations for things you need to do for your job (such as multitasking and detailed production paperwork). Your providers should also discuss your treatment plan and prognosis for returning to work (if you have a goal for that at this point).
"Your self-reported subjective limitations"
The denial letter
New York Life Group Benefit Solutions
Incident Number: 00000000
Policy Name: Employer Name
Underwriting Company: Life Insurance Co of North America
Dear Client:
This letter is about your Short Term Disability (STD) claim. We have separated this letter into subject headings for your ease of reference.
Will You Receive/Continue to Receive Disability Benefits?
After completing our review of your claim, we are unable to continue paying benefits beyond September 5, 2025.
How Was the Claim Decision Reached?
The additional information indicated that you were able to return to work in a part-time capacity based on your self-reported subjective limitations of headaches and light sensitivity.
Our Nurse Case Manager reviewed the September 2, 2025 office visit note. The examination showed you were in no acute distress. Your neck had full range of motion in all directions with no tenderness. You were alert and oriented with intact memory, attention, concentration, language function, affect, and fund of knowledge. Your gait was normal.
Although you have reported symptoms, the medical information provided by your treating physician(s) does not support the restrictions of no work. The available medical information on file does not support a global impairment or provide any quantifiable, or otherwise positive findings to demonstrate that you are unable to function in your current occupation. While we have not stated that your symptoms do not exist, we are stating that the medical information submitted by your treating physician(s) does not support the above definition of Disability as defined by your plan/policy.
You have not presented us with a copy of your Social Security Disability Insurance (SSDI) award letter. Therefore, that information has not been included in our claim decision.
Based on the information provided by your Employer, your claim is governed by the Employee Retirement Income Security Act of 1974 (ERISA). Submit your appeal letter to us within 180 days of your receipt of this letter.
What our review told her
This STD denial with just a few weeks left to go until the end of your claim seems like an attempt to avoid paying an LTD claim, frankly. NY Life is not arguing that your condition improved while you were on STD. Instead, they are basically ignoring the entire claim history to focus narrowly on the September 2, 2025 office visit notes from Dr. Lauritsen. They cherry-pick a few details from that office visit note to say, basically, that you seem able to work full-time. The letter also characterizes your disabling symptoms of headache and light sensitivity as "self-reported." While self-reports may be the only way to determine the severity of your symptoms, from our notes it sounds like you have objective testing to confirm your vestibular dysfunction, plus a treatment history that reflects a serious and disabling condition. NY Life is simply turning a blind eye to all that.
Your draft appeal letter does a good job of explaining the context for your claim. It will be stronger if you can quote from your recent medical records to show the test and exam results that support your claim. It will be stronger still if your doctors will help explain why the conditions they are treating you for are disabling. The more specific they (and you) can be about how your symptoms prevent you from performing required work duties, the stronger the appeal will be. It's important to "connect the dots" between the test and exam results that confirm your medical conditions, the symptoms that those conditions cause, and the very specific work duties you are unable to perform.
"No evidence to support limitations or restrictions"
The denial letter
Standard Insurance Company (The Standard)
Claim: 00000000 Contract: 000000
Employer Plan Name
Dear Client,
We're writing to you about your claim for Disability Benefits with Standard Insurance Company (The Standard). We regret to inform you that you do not meet the Definition of Disability after December 31, 2024. As a result, your Disability extension request has been denied.
Summary of Consultant Review
Medical Opinion: Following your hospitalization your treatment showed improvement as documented by your normal and stable platelet count. Given that there was no recurrence of significant condition, there is no evidence to support limitations or restrictions from January 1, 2025 forward.
My doctor says I cannot work, why do you disagree?
Though your doctor may say you are unable to work or continued to provide limitations and restrictions, we must rely on written evidence to document impairment. We review the medical evidence and/or lack of medical evidence. We also review medical opinions of Physician Consultants and independent physicians.
Finally, simply having a diagnosis is typically not enough to make a disability determination. Rather, it is the severity and frequency of documented symptoms that will determine whether a person is disabled as it is defined by the Group Policy.
Request A Review of This Decision
You have the right to request a review of this decision. To request a review, please send a written request to us within 180 days after you receive this letter. It would be helpful for you to provide medical information showing you had limitations and restrictions from January 1, 2025, which would preclude you from performing your Usual Occupation.
What our review told her
It looks like Standard first approved your Disability claim and continued to pay benefits after you stopped working in August 2024 due to hospitalization for Thrombocytopenia. Standard references an October 2, 2024 approval letter, and that may have more details about whether they reviewed any other conditions (like your underlying autoimmune disease) and whether they made a disability determination about those. But often, approval letters will only give the most narrow reason possible for approving a claim. The insurance company simply ignores any other underlying conditions or other disabling symptoms. It sounds like that may be what happened here.
Practically speaking, outrage will not get us very far for the appeal. It's important to treat Standard's denial as if it is a sincere misunderstanding about your functional capacity for employment, and then work with your doctor(s) to explain specifically why Standard is wrong to say that since your platelet count is normal, you have fully recovered and can return to work.
Specifically, your doctor(s) will need to address this statement on page 2 of the denial letter: "Given that there was no recurrence of significant Thrombocytopenia, there is no evidence to support limitations or restrictions from January 1, 2025 forward." Your doctors will need to explain either why that's not true, or why it's not relevant given your other serious symptoms that do still cause restrictions and limitations. You listed some of your disabling symptoms as "shortness of breath, fatigue, palpitations, immunosuppression due to autoimmune flare ups and medication, treatment required to decrease immune response to autoimmune disease." For the appeal, it will be important to have your doctors 1) show evidence of these symptoms in your medical records, and 2) explain what functional limitations they cause. The more they can refer to "objective evidence" in your medical records, like test and exam results, the stronger your appeal will be.
Each of your treating doctors should address the specific condition they are treating you for (for example, your Pulmonologist can discuss your lung disease and shortness of breath, your Immunologist should discuss your autoimmune condition, your Cardiologist should discuss your heart palpitations, etc.).
It will also be important for you to explain in your appeal letter why having the limitations described by your doctors prevents you from doing your specific job duties as a school nurse. It's usually helpful to get a formal job description and point Standard to the specific required duties that you are unable to perform. You first need to lay out the "dots" of required job duties and doctor-supported limitations, and then "connect" them for Standard in a way that shows why you're unable to do your job.
You also discussed the finances of your claim, which is beyond the scope of what we can really evaluate in this review. If you have any doubts about whether you're being paid correctly, it would be important to get a copy of the Disability policy and a detailed accounting of your payments from Standard.
"Released to return to work full duty"
The denial letter
Aflac
Case Number: 00000000
Employee Name: Client
Benefit Type: Long-Term Disability
Policyholder: Employer Name Corporation
Dear Client,
We've made a decision on your Long-Term Disability (LTD) claim.
We're happy to hear you have been released to return to work on February 2, 2026 full duty. We hope your transition back to work is smooth.
Since you have been released to return to work full duty, you no longer meet the definition of disability effective February 2, 2026. Long Term Disability benefits are payable through February 1, 2026 and we have closed your claim effective February 2, 2026.
If you experience a relapse or you are unable to work again due to the same or related disabling condition, please contact our office so we can discuss how to move forward with your disability claim.
Important Information about Your Appeal Rights
What if I don't agree with this decision? You have a right to appeal any decision in whole or in part.
How long do I have to file an appeal? You have 180 days from the date of your denial letter to file your appeal.
What will the appeal review? The review will take into account all comments, documents, records and other information submitted that relate to the claim. The appeal review will be a "fresh" look at your claim without consideration to the initial benefit denial. The appeal will be reviewed by someone who was not involved in the initial benefit denial.
What our review told him
Your medical conditions sound complex and challenging. Aflac's denial, on the other hand, is fairly straightforward, and rests entirely on their statement that, "you have been released to return to work on February 2, 2026 full duty." To appeal, you and your doctors will need to show evidence that either 1) that is not true, and your doctors did not release you to return to work, or 2) things changed after the supposed "released to return to work" decision and February 2, 2026. The more you and your doctors can rely on evidence in your treatment records to support their explanation, the stronger the appeal will be.
"Subject to the pre-existing condition exclusion"
The denial letter
The Lincoln National Life Insurance Company · Disability and Life Claims
RE: Long Term Disability (LTD) Benefits
Employer Name, S.A.
Claim #: 00000000
Dear Client:
Based on the information received, your claim has been denied and no benefits are payable. The Policy under which you are covered contains the following exclusion regarding pre-existing conditions:
This policy will not cover any Disability or Partial Disability: (1) which is caused by or results from a Pre-Existing Condition; and (2) which begins in the first 12 months immediately after the Covered Person's effective date of coverage.
You submitted a claim for a diabetic foot ulcer. Since your effective date of coverage was February 17, 2025 and your disability occurred on March 18, 2025, we have conducted a pre-existing condition investigation from November 17, 2024 to February 16, 2025.
The medical records received indicate that you were seen on December 13, 2024 which is during the pre-existing condition review investigation period. During this visit, it was acknowledged that you have a diagnosis of diabetes. A medical review was completed which identified that your current impairment is due to a diabetic foot ulcer. The foot ulcer is noted to have been caused by long term diabetes. Because you were seen/received treatment for the diagnosis of diabetes during the pre-existing condition review investigation period, your current impairment falls under the pre-existing condition exclusion.
Therefore, we have determined that your condition is subject to the pre-existing condition exclusion and we must deny your claim for benefits.
Under the Employee Retirement Income Security Act of 1974 (ERISA), you may request a review of this denial by writing to the address below. The written request for review must be sent within 180 days from the receipt of this letter and state the reasons you feel your claim should not have been denied.
What our review told her
Your claim for Short Term Disability (STD) was paid, but Lincoln has denied your LTD claim. They are giving two reasons for the denial:
First, Lincoln says your LTD coverage started February 17, 2025. Since your disability started less than 12 months after that, your LTD claim is subject to the LTD policy's "pre-existing condition exclusion" clause. (This is pretty common, unfortunately... often STD policies do not have this clause, so it's only after a disability extends beyond the STD period that you find out LTD benefits are impacted).
Second, Lincoln says that your disabling condition, which started on March 18, 2025, is "for a diabetic foot ulcer." They also say that on December 13, 2024 you "were seen/received treatment for the diagnosis of diabetes," which was during the policy's 3-month "look back period" from November 17, 2024 to February 16, 2025.
It sounds like Lincoln is right that your LTD coverage became effective February 17, 2025. And they are right that "diabetes" was a Preexisting condition. To win the appeal, then, you and your doctors need to show that your March 2025 disabling condition was NOT caused by and did NOT result from diabetes.
Sandy, based on what you've told us and the information you sent, it sounds like Dr. Woodward and PA-C Wise both support your claim and believe that your disability was caused by your poorly fitting footwear, and not by your diabetes. For the appeal, it would be important for them to review the December 13, 2024 office visit note and explain how the condition you were seen for then did not cause or result in your diabetic foot ulcer in March 2025. Right now, it sounds like everyone is more focused on that March 19, 2025 office visit note, which just establishes that you were treated for a diabetic foot ulcer. Lincoln does not seem to be arguing that the diabetic foot ulcer itself was pre-existing. Instead, they are saying it was "caused by or resulted from" diabetes (which was a preexisting condition).
So, the more important note for the appeal is that one from December 13, 2024. The appeal should discuss why that office visit was not for anything that caused or resulted in your disability.
"A no-work restriction is not medically supported"
The denial letter
New York Life Group Benefit Solutions
Incident Number: 00000000
Policy Name: Employer Name Holdings
Underwriting Company: Life Insurance Co of North America
Dear Client:
This letter is regarding your Long Term Disability (LTD) claim. We advised you that we were conducting an evaluation to determine your eligibility for benefits beyond June 21, 2025 which is when your policy's definition of disability changes.
After Disability Benefits have been payable for 24 months, the Employee is considered Disabled if, solely due to Injury or Sickness, he or she is unable to perform all the material duties of any occupation for which he or she is, or may reasonably become, qualified for based on education, training, or experience.
Following a review of your claim with our MD, we have determined that while you are functionally limited, a no-work restriction is not medically supported.
We then referred your claim to our vocational department for review for a Transferable Skills Analysis. They considered your work capacity, restrictions and limitations, along with your education and employment history, to determine occupations that you would be able to perform. This review confirmed that you would be able to perform the following sedentary occupations:
Customer Order Clerk eDOT 249.362-026
Specialist Client Services eDOT 205.362-004
Because we have determined that you are able to perform the material duties of the identified occupation(s) for which you are, or may reasonably become, qualified based on your education, training or experience, you do not satisfy paragraph 1 and are no longer Disabled as defined.
At this time, you no longer meet the definition of Disability stated above and your claim has been closed. Based on the information provided by your Employer, your claim is governed by ERISA. Submit your appeal letter to us within 180 days of your receipt of this letter.
What our review told her
As you know, NY Life first approved your LTD claim because they agreed that you were unable to work in your physically demanding occupation as a Business Service Sales Agent (your "own occupation"). After two years, the policy definition of "Disabled" changes. To continue receiving benefits, you need to prove that you remain unable to work in any occupation, even a less-demanding sedentary one.
In the denial letter, NY Life relied heavily on cherry-picking the few elements of your physical exams that were "normal," while ignoring all the evidence supporting your claim. The denial letter tries to pass off all your pain as being related to fibromyalgia and not your rheumatoid arthritis and orthopedic conditions. NY Life's Medical Director agrees that you still could not work at your own job, but says that your restrictions don't "seem" severe enough to prevent you from working entirely. NY Life then invented a set of specific restrictions and limitations for you that, unsurprisingly, would allow you to work a sedentary job. Then they "found" two sedentary jobs they said you were qualified for (Customer Order Clerk and Specialist Client Services, which are intentionally vague job titles) and closed your claim. NY Life ignored your SSDI award entirely, which they are not supposed to do – they should at least try to explain why their decision is different from the Social Security Administration.
To appeal, you are going to need at least one doctor (preferably Dr. Khan and/or Dr. Nguyen) to explain why NY Life is wrong, and you cannot do the specific job-related things you need to do even for a sedentary job. Since your conditions affect your ability to use your hands, if your doctors can explain that you are unable to use your hands for several hours a day (as NY Life claims) for activities like typing, that can be very helpful for your claim. Any other specific disagreements with the list of "reasonable restrictions" NY Life came up with on page 4 of the denial letter would also be helpful.
It may also be useful to talk with your doctors about a Functional Capacity Evaluation (FCE). Some Physical Therapy practices offer these evaluations, which can quantify your actual restrictions and limitations and show that NY Life is overestimating your true capacity for sustained work. If a valid FCE shows you have less functional capacity than the insurance company estimates, that can be all they need to approve your claim.
It may also be useful to get a copy of your complete file, or at least your DDE (Disability Determination Explanation) from the SSA. If the SSA found that you either did not have the physical capacity for sedentary work, or that you did not have the training, education or experience to qualify for sedentary jobs, that's really important evidence to include with your appeal. Sometimes it helps to go in person to your local SSA office to get a copy of your file. If an advocate helped you get approved for SSDI, they may also have a copy of your file or at least your DDE.
Billie, based on the notes we have from you, it sounds like you are on the right track with what you are focusing on for the appeal. The only shift we would suggest would be to make sure your arguments also come from your treating providers and are supported wherever possible with test and examination results, especially from June 2025 and forward. Insurance companies are set up to pay far more attention to what your doctors say in their office visit notes than to what you say about your claim, unfortunately.
Your denial letter has a story too
Send us your denial letter and we'll tell you what it really says, what a strong appeal would need, and how we can help. There's no charge for your review.
Get your free denial letter review