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Artificial intelligence may help an insurer organize records or analyze information, but it does not change the disability definition in your policy or eliminate the legal protections that apply to your claim. If a review misstates your medical history, overlooks functional limitations, or misunderstands your occupation, those errors should be addressed with specific evidence before the applicable deadline.
For people receiving or seeking long-term disability (LTD) benefits, the practical questions are whether the insurer considered the complete record, applied the correct policy terms, and gave a supported explanation for its decision. Those questions matter whether a review involves human judgment, software, or a combination of both.
How AI may be used in insurance reviews
Insurance companies use technology for many purposes. The National Association of Insurance Commissioners (NAIC) has addressed the use of artificial intelligence in insurance and adopted a model bulletin concerning insurer oversight of AI-supported decisions. The bulletin is a regulatory model; its application depends on the relevant jurisdiction. It is not evidence that a particular insurer used AI in a particular LTD claim.
Potential uses of AI-assisted tools include summarizing lengthy records, extracting dates and diagnoses, or identifying information for further review. Ordinary automation, data analytics, and AI are not interchangeable terms. A standardized denial letter or a fast decision, standing alone, does not establish that AI was involved.
Claimants should avoid assuming how their file was processed. The more useful starting point is to examine what the insurer actually said and whether its conclusions are supported by the underlying evidence.
Can an insurer use AI to deny an LTD claim?
The use of AI does not, by itself, establish that a denial is lawful or unlawful. The decision must be assessed under the policy and applicable law. For an employer-sponsored plan governed by ERISA, federal claims-procedure rules require a full and fair review. Individually purchased disability policies generally require a separate analysis under the contract and applicable state law.
An appeal should identify the actual defects in the decision. For example, did the reviewer overlook a physician’s explanation, use the wrong occupational standard, or rely on an inaccurate summary? An unsupported allegation that AI caused the denial is less useful than a documented explanation of what the insurer got wrong.
Why medical summaries must explain functional limitations
A diagnosis alone may not establish disability under a policy. The evidence should explain how symptoms, treatment, and medication effects interfere with the duties relevant to the claim. The applicable standard may involve your own occupation or another occupation, depending on the policy and the stage of the claim.
Fatigue, pain, migraines, cognitive difficulties, and fluctuating symptoms can require careful explanation. A summary focused on diagnoses or isolated examination findings may fail to capture whether a person can sustain attendance, concentration, pace, or physical activity over a workweek.
Consider a hypothetical executive whose records describe cognitive fatigue and medication-related drowsiness. A summary that lists normal strength and an ability to drive may leave out the limitations affecting sustained judgment and concentration. The response should identify the omitted records and connect those limitations to the applicable occupational duties. This example illustrates a possible review error; it is not an assertion about a specific insurer or case.
Why surveillance and other red flags need context
Surveillance, social media posts, travel, treatment gaps, and inconsistent statements may be relevant evidence. They do not automatically establish that a claimant can perform the work required by the policy.
A brief activity may reveal little about the assistance required, symptoms afterward, frequency of the activity, or ability to repeat it throughout a workweek. Conversely, activity that materially contradicts reported restrictions may affect a claim. A meaningful response addresses the specific evidence honestly and explains its context.
If a treatment gap reflects cost, access problems, medication intolerance, or a physician’s recommendation, document that explanation. Do not assume the reviewer will infer it from the file.
What to request when a disability review contains errors
Start with the denial letter and the evidence the insurer identifies. For an ERISA-governed claim, request the relevant claim documents, records, and information available under the claims-procedure rules. Depending on the file, these may include medical and vocational reviews, claim notes, and materials explaining the decision.
If there is a reason to believe an automated or AI-assisted output affected the determination, ask whether such a tool was used and request relevant outputs or summaries. Do not assume that every request will entitle you to proprietary software, source code, or all information about the insurer’s systems.
A focused response should:
- Identify each factual error or omission and cite the supporting record.
- Explain the policy definition that applies and the occupational duties at issue.
- Obtain a physician’s clarification when the review mischaracterizes symptoms or restrictions.
- Address adverse medical, vocational, surveillance, or other evidence directly.
- Preserve the appeal deadline while developing the response.
For disability appeals subject to the applicable ERISA regulations, the administrator must provide new or additional evidence, and any new or additional rationale, sufficiently before the appeal decision to allow a reasonable opportunity to respond. These protections are particularly important when a review introduces conclusions the claimant has not previously had an opportunity to address.
Why treating physician reports and the appeal record matter
Detailed physician reports should connect medical findings and clinical observations to specific functional restrictions. Where appropriate, they should address symptom variability, medication effects, and the ability to sustain work over time.
In Black & Decker Disability Plan v. Nord, 538 U.S. 822 (2003), the Supreme Court explained that ERISA does not require automatic special weight for treating physicians’ opinions. It also stated that administrators may not arbitrarily refuse to credit reliable claimant evidence, including treating physician opinions.
The evidence needed depends on the reasons for denial. Some appeals benefit from a vocational assessment, functional evaluation, or neuropsychological testing; others call for targeted clarification of records already available. Testing should serve a specific evidentiary purpose.
In ERISA litigation, courts frequently focus on the administrative record developed during the claim and appeal. Rules about additional evidence vary by jurisdiction and standard of review. Claimants should therefore treat the administrative appeal as a critical opportunity to present their evidence rather than assume missing proof can be supplied later in court.
How insurer conflicts fit into the analysis
In Metropolitan Life Insurance Co. v. Glenn, 554 U.S. 105 (2008), the Supreme Court held that an administrator’s dual role in deciding eligibility and paying benefits creates a conflict of interest. In judicial review of a discretionary benefits decision, that conflict is a factor whose importance depends on the circumstances. It does not automatically invalidate a denial.
Glenn is not an AI-specific decision. Its relevance is the broader need to examine how the determination was reached and whether the insurer fairly evaluated the evidence.
Getting help with an LTD denial or termination
The most effective response to an inaccurate review is a complete, organized record that explains why you satisfy the policy’s disability definition. Keep copies of insurer communications, review questionnaires carefully, and ask treating providers to describe the limitations that affect your work. Seek advice promptly when benefits are denied or terminated, because appeal and lawsuit deadlines may apply.
The Law Office of Justin C. Frankel, P.C. represents claimants in long-term disability insurance claims, appeals, and litigation nationwide. We evaluate the stated reasons for denial, the governing policy, and the medical and occupational evidence to determine how to challenge an adverse decision.
If your LTD benefits have been denied or terminated, contact our office to discuss your claim and the steps needed to protect your appeal rights.
Contact the Law Office of Justin C. Frankel, P.C. today for a free consultation (516) 222-1600 and learn how an experienced ERISA disability attorney can help protect your rights and maximize your chances of success.
Justin C. Frankel is the founder of the Law Office of Justin C. Frankel, PC, a Long Island, New York headquartered law firm representing clients nationwide in disability insurance claims. For more information please go to our website www.jfrankellaw.com.
This article is provided for informational purposes only and does not constitute legal advice. Every disability insurance claim depends upon the specific policy language, medical evidence, occupational requirements, and circumstances of the individual claim.
The post Artificial Intelligence and Long-Term Disability Claims: What to Do When an Insurer’s Review Gets It Wrong first appeared on Law Office of Justin Frankel written by Justin C. Frankel .
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📰 This article is sourced from a trusted insurance industry publication. Legacy Life Insurance Group shares this for informational purposes only. Always consult a licensed advisor for personalized guidance.