As with any case it is important to have both damages and liability in order for a long-term disability claim to be a good case.  I will start off with a checklist of some basic matters and then explain further:

1.     Are there adequate damages or amounts at stake?

2.     Is there substantial medical evidence? Self-reported complaints will not likely be adequate.

3.     Is there vocational evidence supporting the definition of disability?

4.     Are there problems with a full and fair review?

5.     Is there a reservation of discretion in the plan document?

6.     What are the policy limitations?

7.     Have claim exhaustion procedures been followed?

First, as to damages, there will be no recovery for mental anguish or punitive damages and so the damages are limited to past-due benefits.  If the case goes into litigation there may be interest added to past-due benefits, and the claimant can seek attorney's fees for time spent in litigation including preparation of the lawsuit. Damages run from the date the claim is terminated or denied and then end with the court decision if ongoing proof of loss was furnished during the litigation. If not the ruling may go back to the date of the last denial or termination or when proof of loss was last furnished.. Courts cannot award future benefits.

Second, the claim must be supported by substantial medical evidence demonstrating that the claimant meets the definition of disability in the plan document. That might be an inability to work in one's own occupation or an inability to work in any occupation.  It is critical then to have your plan document, or summary plan description at the very least, so that you know the definition of disability.

Third, the claim may need to be supported by substantial vocational evidence. Medical evidence demonstrates restrictions and limitations and perhaps a doctor may be familiar with job requirements and opine on the fact that the client cannot perform the job in question.  However, generally a vocational consultant may be necessary to understand the components and physical demand requirements of the client's occupation or any occupation the client might be qualified to perform by reason of the client's training, education, or experience due to illness or injury.

Fourth, was the claim terminated or denied following the requirements of a full and fair review? The statute requires claim decisions are both full and fair but then delegates to the Department of Labor to decide what constitutes a full and fair review. That regulation is found at 29 CFR §2560.503-1.  If there are problems with a full and fair review, then good cause should be requested from the decisionmaker for any violations within 10 days. If that is not furnished it might have a bearing on the standard of review to be conducted by a court.  The process should be a thorough and principled decision-making process.

Fifth, what is the standard of review in the plan document? If it is the arbitrary and capricious standard of review, then one must not only demonstrate that the decision was wrong but further must show that it was arbitrary or unreasonable.  If there was no full and fair review, the court may allow an easier standard of review called de novo review which only requires proof that is more probably than not in your client's favor. Also, if the plan document does not reserve discretion implicating the arbitrary and capricious standard of review, then that review also will be a de novo review.

Sixth, are there limitations in the policies such as a pre-existing condition limitation or a limitation for certain conditions such as a mental nervous condition? That can also limit the damages at stake.

Seventh, have the claim exhaustion procedures been followed? If the claim was terminated or denied there must be a timely appeal or challenge to that termination before filing a lawsuit. Otherwise, futility must be demonstrated to excuse the exhaustion requirement such as severe violations of the claim procedure regulation for a full and fair review.

There is a case that demonstrates the importance of many of these factors, Wild v. Unum Life Ins. Co. of Am., No. 3:23-CV-986-BJD-LLL, 2025 U.S. Dist. LEXIS 16796 (M.D. Fla. Jan. 29, 2025).  Ms. Wild had chronic neck and bilateral shoulder pain. MRIs documented radiculopathy as well as foraminal stenosis and bulging discs. Ms. Wild further had back surgery at the Mayo Clinic, a lumbar fusion, which left her with ongoing pain, having difficulty sitting, standing, and walking.

Unum paid the claim for a while because Ms. Wild only had to prove she was disabled from performing her occupation. However, when the definition under the plan document changed to requiring proof of disability from performing any occupation, Unum dug in and relied on its often used doctors to support a termination of benefits.

In the end, even though she had evidentiary support such as an FCE, and vocational proof along with a physician report, nonetheless Unum's regularly utilized doctor said that despite the FCE, there was no correlating findings on examination by the attending physician to support the FCE restrictions.  Ms. Wild appealed and Unum continued to refuse to pay the claim.

After Ms. Wild filed a lawsuit, the Court agreed that under a de novo standard of review, she was right and had proven disability.  However, under the arbitrary and capricious standard of review, Unum had some reasonable basis to disagree and terminate the benefit and therefore the court ruled for Unum.

There are many other twists and turns with ERSIA long term disability.  The focus, however, is always on building a strong claim record during the claim process.  Don't tell your client to call you when it is time to file suit. They need counsel before the claim is exhausted. That is where the key work is done.