When Your Insurer Says No, We Say Fight Back
Your Insurer Has a Conflict of Interest. We Don't.
Long-term disability insurers make money by collecting premiums and minimizing claims. When your doctor says you cannot work, and your insurer says you can, you are caught in the middle of a system designed to deny you.
SMDA has spent years fighting disability insurance companies on behalf of clients who paid for their coverage and were denied when they needed it most. We know the tactics these companies use — the surveillance, the paper reviews by doctors who have never examined you, the shifting definitions of disability — and we know how to counter them.
Understanding ERISA — The Federal Law That Governs Your Claim
Most employer-provided long-term disability policies are governed by ERISA, the Employee Retirement Income Security Act. ERISA is a federal law that imposes a unique and unforgiving framework on disability claims: there is no jury trial, courts give significant deference to the insurer's decision, and review in federal court is generally limited to the administrative record — meaning the documents already in the claim file at the time of the final denial.
What this means in practice is that your case must be won at the administrative appeal stage, before it ever reaches court. Every medical record, every expert report, every functional capacity evaluation, and every legal argument must be made part of the file before the insurer issues its final decision. If your attorney waits until federal court to build the record, it is too late.
SMDA approaches every ERISA claim with this in mind. We build a complete, evidence-rich administrative record from day one — and when litigation becomes necessary, our case is already prepared.
The Disability Claim Denial Process
- 1
Claim Filed
You submit your initial claim with medical records, employer information, and proof of disability.
- 2
Initial Denial
The insurer reviews and denies — often citing surveillance, paper reviews, or shifting policy definitions.
- 3
First-Level Appeal
You have a limited window to appeal. This is when the administrative record must be built — comprehensively.
- 4
Second-Level Appeal
If the first appeal is denied, a second appeal may be available. SMDA strengthens the record at every stage.
- 5
Federal Court Litigation
If administrative appeals fail, we file suit in federal court — armed with the record we built from the beginning.
Common Reasons Disability Claims Are Denied
'Own Occupation' vs 'Any Occupation'
Most policies pay 'own occupation' benefits for the first two years and shift to a stricter 'any occupation' standard after. Insurers often use this transition to terminate benefits without warning.
Surveillance and IMEs
Insurers hire investigators to videotape claimants and 'independent' medical examiners to conduct one-time exams. We counter both with detailed medical evidence and treating physician testimony.
Incomplete Documentation
Many denials cite missing records, gaps in treatment, or inadequate functional capacity evaluations. SMDA fills those gaps systematically before the appeal deadline.
Pre-Existing Exclusions
Insurers frequently invoke pre-existing condition exclusions — even when the claimed disability is fundamentally different from the prior condition. These exclusions can often be defeated on appeal.
Conditions We Have Helped Clients With
Disability comes in many forms, and insurers approach each one with its own playbook. Chronic back and neck pain claims are often dismissed as subjective despite imaging evidence. Fibromyalgia and multiple sclerosis claims are challenged on the basis of fluctuating symptoms. Cancer-related disability often hinges on cognitive impairment from treatment that insurers refuse to credit.
Mental health conditions — depression, anxiety, PTSD — face additional hurdles, often subject to limited benefit periods and aggressive surveillance. Cardiac conditions are evaluated by reviewing physicians who never see the claimant. SMDA understands the specific tactics used in each category and tailors the appeal accordingly.
What SMDA Does Differently
We start by reading every page of your policy — the master plan, the summary plan description, the riders, the schedule of benefits. We build a comprehensive medical record that includes treating physician statements, functional capacity evaluations, and where appropriate, vocational expert testimony establishing what work you actually cannot perform.
We write detailed appeals that address every basis cited in the denial, supported by medical literature, vocational evidence, and policy language. And when the insurer still refuses to honor its obligations, we litigate aggressively in federal court — with the record already built and ready.
Disability Claim Recoveries
A long-term Cigna claimant whose benefits were terminated after the 'any occupation' transition was reinstated and made whole after SMDA's appeal documented the cognitive limitations the insurer ignored.
A cancer survivor whose claim was denied based on a paper review by a physician who never examined her recovered her benefits in federal court after SMDA established the inadequacy of the review.
A client with fibromyalgia, told her condition was 'too subjective' for benefits, was reinstated on appeal after SMDA built a record of objective functional limitations and treating specialist testimony.