Claims for long-term disability benefits are routinely denied by insurance companies. They deny them for any number of different reasons, but the most common is that there isn’t enough medical evidence to support the claim that your condition is preventing you from being able to do your job. This can be hard to comprehend for someone who just spent weeks or months seeing doctors and specialists and getting scans and tests done. Despite the aggravation and disappointment, however, it’s crucial that you don’t give up.

If you need to file a claim for LTD benefits, or your claim was denied, partner with a disability lawyer in Toronto who has helped thousands of clients get the benefits they deserved after their insurance companies denied their claims.  We know how to prove that our clients meet the eligibility criteria for benefits as stated in the insurance contract and how to force insurance companies to honour those contracts.

The information in this post will help you gain a better understanding of how vital it is to have medical evidence to support your claim, the standard that evidence must meet and what to do if your claim is denied to get the financial support you need when you need it most.

Disclaimer: The information in this guide and everywhere else on this website is for general information only and is not intended to provide legal advice of any kind. No lawyer-client relationship is created by accessing or otherwise using Ertl Lawyers’ website or by communicating with a lawyer or staff member. Please contact the leaders in employment and disability law at Ertl Lawyers if you need legal advice. We’re more than happy to speak with you.

When Does an Illness or Injury Become a Disability?

To understand just how critical it is to have the right medical evidence to support your claim, it helps to have the background knowledge of how short- and long-term disability claims are assessed.

In a nutshell, long-term disability policies provide benefits when people are experiencing an injury, illness or medical condition that is so severely painful or debilitating that it prevents them from completing the most substantial parts of their work and they’ve already used up all their sick leave in Ontario.

This is known in the insurance world as being “totally disabled” from the ability to perform your “own occupation”, i.e., the type of work that you’ve been trained to do. If you are unable to work at all, you are considered to be “totally disabled” from “any occupation.” That is a higher standard that you don’t need to meet at this stage.

What Kind of Information is Usually Needed on an LTD Claim Application?

Aside from your personal, work and financial information, an application for long-term disability benefits will also require a detailed account of your medical history and the circumstances that caused the condition that is disabling you.

The application will usually include:

• When you became injured or ill or when you became aware of it.
• A list of healthcare providers you’ve seen and their notes from your visits.
• Any and all treatment and medication you’ve received.
• The date that you stopped working.
• A diagnosis of your condition from a doctor or specialist.
• The healthcare provider’s prognosis and treatment plan.

Everything you tell a doctor becomes a part of your medical records and your healthcare provider is the one who fills out the medical portion of the LTD claim application. So, when you speak to healthcare providers, be honest and as descriptive as possible about how and what you feel. It helps to keep a journal and to write down what you experience as part of your symptoms. For example, when experiencing physical pain, as soon as you can, write down the:

• Activity or movement that caused the pain.
• The type of pain you experience: throbbing, stabbing, pulsing, burning, etc.
• Where in the body the pain is coming from.
• How severe it is.
• How long symptoms last and how frequently they return.

How Medical Evidence Impacts a Long-Term Disability Claim

The most crucial part of your LTD claim application is the Attending Physician’s Statement provided by your doctor or specialist. It’s typically a boilerplate form provided to your doctor with checkboxes for them to indicate your ability to perform various physical and cognitive tasks.

For your claim to have a chance of approval, the physician’s statement must clearly and convincingly show how your injury, illness or medical condition specifically prevents you from being able to complete the tasks that are essential to your work.

If you were provided a job description when you were first hired, give a copy to your doctor and go through each of your duties/functions and describe what you need to do to complete each one and how your condition or symptoms either prevent or interfere with the functional abilities needed for each.

If the LTD form doesn’t provide enough space for this, have your doctor attach a separate sheet.

However, a physician’s statement alone is typically not enough to rely on for an approval of LTD benefits. The more documentation you can provide to support your claim, the better. If your disability is caused by an illness or injury that can be shown in a blood test, x-ray, MRI, etc., you should include it with your application. The problem is, there are many medical conditions that can disable your ability to effectively do your job that are not verifiable by “objective evidence.”

That said, medical evidence to support your claim is the most important part of your application.  Along with this medical evidence, it is equally vital that you follow the treatment plan recommended by your doctor to ensure that the insurance company can’t revoke or deny benefits on the basis that you are trying to remain disabled by refusing treatment.

Ensure you take the time to fill out the forms with your doctor to ensure they are capturing your illness or injury as accurately and descriptively as possible to help your case.

LTD Benefits Claims and ‘Invisible’ Illnesses

Insurance companies often deny claims based on a decision that there is no “objective evidence” to prove the medical condition or that it’s severe enough to meet their definition of a total disability. This is often the case with medical conditions with no visible signs of injury or ‘invisible disabilities’. Examples include:

• Chronic pain
• Deafness
• Learning disability
• Mental illness
• Head injuries
• Chronic Fatigue
• Epilepsy
• Lyme Disease
• Fibromyalgia disability
• Thoracic Outlet Syndrome
• Cancer
• Non-cancerous tumours
• Arthritis
• Inflammatory Bowel Disease

If you suffer from one of these conditions or any other ‘invisible’ disability, it may be easier for the insurance company to deny them. But for an experienced disability law firm, getting our clients benefits from their denied mental health disability claims is just another day at the office.

Our clients often come to us after they’ve received a denial letter and ask what their options are. This is what we tell them:

What to do if Your Claim is Denied

If your LTD benefits claim is denied or the insurance company notified you that they are stopping your benefits, you can still get the financial support you need, but the clock is ticking. Here’s what you can do.

Appeal the Decision Using the Insurance Company’s Appeals Process

Insurance companies are required by law to honour legitimate claims and act in good faith. To show that they’re complying with those obligations, they set up an appeals process and tell their clients they can appeal an LTD denial through their appeals department. But there are no laws that dictate how the insurance companies should run these departments or otherwise try to avoid a conflict of interest.

So internal LTD denial appeals are managed and decided by employees of the same insurance company that denied your original claim. Unless something about your claim has drastically changed, it’s unlikely they will reverse the denial.

Also, an insurance company’s appeal process often forces an already injured or ill person to travel to various doctor’s offices, clinics and diagnostic centres for more assessments and documentation while their appeal process drags on for months and has multiple levels of appeal.

If an insurance company denies your claim for LTD benefits, your only other option is to take them to court, but you only have two years from receiving the denial letter to file one. By the time you’ve gone through their appeals process, there usually isn’t enough time left.

File a Lawsuit Against the Insurance Company

It’s in an insurance company’s financial interests to deny as many claims as possible and drag their feet on the appeals process that usually ends in another denial. Threatening them with a lawsuit is often the only way people who disabled can receive the support they need and are entitled to and that’s what we do on our clients’ behalf.

We file a Statement of Claim against your insurance company telling them we intend to sue for:

• The benefits you should have received but were denied.
• The benefits you should have been receiving between the denial and when the case settles or a trial is completed.
• Punitive damages if your insurance company acted in bad faith.

Often, when we let the insurance company know that we are now representing you, that’s enough to get them to negotiate a settlement that gets you the benefits you need and deserve.