Long Term Disability Denials

Whether your job is something you love doing, an integral part of your identity, or simply a way to pay the bills, finding yourself unexpectedly unable to work for an extended period of time can be an incredibly destabilising experience.

People who are seriously injured or who suffer from the debilitating effects of an illness or chronic medication condition may discover that relying solely on regular sick days will not give them enough time to recover and return to their job. Fortunately, many of us have access to disability benefits through a group plan paid for by an employer, a self-funded private individual plan, and/or through the Canada Pension Plan disability benefits program to cover a portion of your lost income if we cannot work for a period of weeks, months, years, or ever again.

Obtaining these benefits can present some challenges, however; especially if an applicant seeks to qualify for long-term disability payments. Insurers can and do deny benefits to people in need if their applications contain errors or omissions, if they believe the terms of insurance policy have not been met, or if they dispute the nature or severity of a person's disability.

Discovering you will not receive regular income replacement payments at a time when your condition prevents you from working is incredibly worrying. You might wonder how you will be able to support yourself or your family, and fear the consequences for your health if you are forced to attempt a return to work early.

If you are concerned about your long-term disability application, experience unreasonable delays once you've applied, or believe you have been unfairly denied benefits, it's in your interest to consult a long-term disability lawyer - and Gluckstein Lawyers' LTD benefits claims team is ready to help. As one of Canada's top ranked personal injury firms, you can trust us to work diligently and effectively for you.

How to Make a Benefits Claim​.

If you are seriously injured or become ill, you may be eligible to apply for disability benefits. The qualifying period before you can apply for benefits varies according to each policy, and you may be required to exhaust any regular sick days prior to applying. Applications are made directly to the insurer according to the terms of your policy. You will be assigned a claims specialist to facilitate payments and monitor your recovery progress.

Generally, group or individual private plans first provide short-term disability benefits for a period of between four months to one year. Your doctor or medical practitioner will be required to file reports outlining the nature of your disability, a treatment plan, and the date when they anticipate you will be able to return to work.

If you remain unable to work as the short-term disability period draws to a close, you will need to begin work on a long-term disability application. This application requires additional medical reports, and an insurer may require you to be assessed by an independent medical practitioner of their own choosing.

Qualifying for Long-Term Disability Benefits​.

To qualify, generally, you will need to demonstrate that:

• your condition or illness meets the policy's definition of a disability;
• your disability is not excluded based on the policy's language (for example: a pre-existing condition that disables you shortly after you were employed, refusing medically necessary treatment for certain types of conditions, a disability sustained when committing a criminal act, etc.);
• your disability prevents you from working at your "own occupation" (some policies use this language during the first two years);
• your disability prevents you from working at "any occupation" suitable for a person with your level of education, training, and/or experience (often after two years on LTD under the "own occupation" language); and
• you have passed the qualifying period (waiting period) to receive the benefit.

Some common conditions or disabilities which may be covered by LTD policies include:

• Chronic nervous system conditions (chronic fatigue syndrome, fibromyalgia, and autoimmune disorders such as Multiple Sclerosis, Rheumatoid Arthritis, Crohn's Disease, or lupus)
• Orthopedic injuries (fractures and musculoskeletal dislocations and tears)
• Cardiovascular disease (strokes, coronary heart disease, aneurysms)
• Mental illness (anxiety disorders, depression, and post-traumatic stress disorder) and addictions
• Traumatic Brain Injuries (TBIs), including concussions
• Cancer and after effects of cancer treatment

In some cases, your disability will clearly prevent you from working at your own or any similar occupation. But in other cases, an assessment may indicate that you should be able to return to work or hold another job if certain accommodations are put in place. Sometimes a person on short-term or long-term disability will want to try to return to work even if they have not been cleared by medical practitioners.

If you attempt to return to work prior to being approved for LTD, or while on LTD, you should first consult with an LTD benefits claims lawyer. Understanding your rights and the rules in your specific policy will allow you to make an informed choice and minimise disruption of income or income-replacement benefits if the return is unsuccessful.

Common Reasons for Denied Disability Claim.

​Disability claims can be denied for a variety of reasons. Some, such as clerical errors or omissions, can be corrected without much difficulty. Other reasons may be more difficult to contest.

An applicant's LTD claim may be denied if:

• a policy exclusion applies (for example, length of employment prior to injury)
• the application contains inaccurate or missing information
• documentation demonstrating disability is insufficient
• the applicant has failed to follow reasonable treatment/rehabilitation plans
• surveillance suggests an applicant is not sufficiently disabled to qualify or provides evidence of insurance fraud

It's important to remember that just because an insurance claims adjuster believes an application for LTD should be denied, it does not mean you do not rightfully deserve these benefits. There are many instances where LTD denials have been based on faulty reasoning. For example:

• The applicant's own medical practitioner notes and reports are indecipherable or incomplete.
• The insurer's third-party medical examiner does not adequately take into account your pre-injury baseline health when assessing ability.
• The insurer's third-party medical examiner uses an unreasonable standard when assessing the nature of your disability.
• The insurer incorrectly asserts that an applicant must strictly follow a treatment/rehabilitation plan when such adherence may be unreasonable due to the nature of your injury or disability.
• Surveillance reports that indicate a person is not sufficiently disabled comes from a "good" day or period of time, but not indicative of their baseline health and ability.
• Surveillance reports capture a person following elements of a treatment plan that appear to contradict the stated nature of their disability (for example, a person experiencing depression is encouraged by their doctor to spend socialising or pursuing pleasurable outdoor activities when their condition would otherwise cause them to want to stay home alone).

What to Do if Your Long-Term Disability Claim Has Been Denied.

​When most insurers send a denial of long-term benefits letter, they will outline an internal appeals process. While it might appear to be a logical next step to take, the internal appeals process is rarely successful. Moreover, participating in a long, drawn-out internal appeal may significantly limit your ability to seek remedy from the court if the appeal is unsuccessful.

Therefore, you should seek independent legal advice before responding to this notice or attempting to return to your job. A knowledgeable, skilled, and experienced LTD benefits claims lawyer can help you to determine if filing notice of a civil claim against the insurer would be in your best interest.

By filing notice of a claim, your legal representative will be able to communicate with your insurer directly and offer to enter negotiations to achieve a fair settlement. While some LTD claims go to trial, often the insurer will consider making a settlement offer when presented with a compelling case.

Gluckstein Lawyers has helped many people just like you or your loved one who have been unfairly denied benefits. In a free, no obligation initial consultation, we'll review the details of your situation, explain your options, and answer any questions you may have. If we believe we can successfully negotiate a fair settlement for you or win a court award, we will gladly offer to represent you.

At a time when you should be focused on healing, you need a strong and dedicated legal representative who knows how to deal with difficult or unreasonable insurers. As your tireless advocate and supporter, we'll work on your behalf to get the resources you deserve in your time of need.

To learn more about how we can help, contact us here.