Having your claim for long-term disability benefits denied or your benefits terminated, adds to an already stressful situation. It’s important to know, however, that you still have an opportunity to get the benefits you need, but there’s a time limit on your options which began around the time you received the denial letter.
It is highly recommended that you speak with a long-term disability lawyer immediately.
You have two options to dispute the insurance company’s decision and fight for the benefits you need and are entitled to. You can use the insurance company’s internal appeal process or you can file a legal claim against the insurance company in court.
Keep reading to gain a better understanding of the LTD process which can help you make an informed decision.
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. If you need legal advice, please contact our staff at Ertl Lawyers. We’re more than happy to speak with you.
What to Expect Next and First Steps
The denial letter will guide many of your decisions and actions moving forward. Because your options are now all time sensitive, you need to know what your deadlines are. Look for the date the decision was made as that is when the clock started ticking. Mark this date on your calendar.
The denial letter will also tell you how long you have to appeal their decision. It’s a good idea to mark this date in your calendar as well, should you choose this option.
The insurance company may also send a letter to your employer, telling them that your claim for long-term benefits was denied. If your employer asks when you will be coming back to work, you can advise them that you are still disabled and filing an appeal. If your employer isn’t satisfied with that answer, you can ask your doctor to issue you another doctor’s note excusing you from work. You must also speak to your long-term disability lawyer if your employer insists that you come into work.
Your next step is to gather all the documentation related to your claim: a copy of your policy, a copy of your claim (if you have it), any medical reports, doctor’s notes and the denial letter. Whichever option you choose, you will need as much information as you can get.
Option I – Using the Insurance Company’s Appeal Process
If you decide to use the insurance company’s appeal process you will have to be 100% clear about their reason for denying your claim. Moreover, you should have a compelling reason to believe that you can remedy the deficiency and that your appeal will be granted. Otherwise, depending on how long the appeal takes and when you see a disability lawyer, your window may have already closed on your other option if this one fails.
Option 2 – Filing a Lawsuit Against the Insurance Company
You have two years from the decision date on your denial letter to file a legal claim against the insurance company. This may seem like a lot time, but both of your options take time and preparation. You will likely also have to attend other medical appointments, assessments and evaluations on top of the care you’re already receiving
Before deciding which option is the best route to take, it helps to understand why long-term disability claims get denied. Having that background information helps you better understand your chances of success appealing your LTD denial.
Why Long-Term Disability Claims Get Denied by Insurance Companies
Insurance companies routinely deny long-term disability claims, it’s important not to get discouraged or give up. If your LTD application was denied, it was likely for one of the following reasons:
Application Filed After the Deadline
Your policy will advise you of the amount of time you have to file a claim. That time begins when you become aware of your disability and you cannot file a claim after it has expired. A claim denied for this reason must be fought in court.
Exclusion/Ineligibility Because of a Pre-Existing Condition
When using a pre-existing condition clause, the insurance company claims that the start of your disability, such as the first symptoms, began before the date you became insured. They will then deny your LTD claim by asserting that either you are ineligible for benefits or that you made misrepresentations on their application forms by not including information about your pre-existing condition.
A Lack of Medical Evidence to Support Your Claim
This is one of the most common reasons for denying a long-term disability claim. The insurance company will state that the disability you are claiming hasn’t been proven by the medical evidence submitted with your application. Unfortunately, this is common with mental health disability claims.
The insurance company will deny the claim because of a lack of “objective evidence” such as blood tests, MRIs, x-rays, etc. But many conditions, including:
- Depression, anxiety, PTSD and other mental illnesses
- Chronic fatigue or pain
Do not appear on scans or in blood tests as they are well aware of.
You can also be denied for lack of medical evidence even if you submit tests, diagnostic imaging, etc. The insurance company may simply disagree with what your doctors and specialists have reported.
Failing to Comply with Treatment or Insurance Policy Requirements
The insurance policy may require that you meet with a medical examiner chosen by them for an “independent medical examination (IME).” While they are often meant to disprove your claims, you must still attend them and let your lawyer know.
It’s also crucial that you attend all other appointments and follow your doctor’s treatment plan. If the insurance company put you on a treatment plan and you are unable to keep up with it, let your doctor know and speak to a disability lawyer immediately.
You Are No Longer Disabled
If your application is approved and you receive LTD benefits, the insurance company may stop those benefits by claiming that you are no longer disabled. They can base this decision on information reported during an IME or conditions included in the policy.
When someone first starts receiving LTD benefits, they are unable to perform the tasks of their current job or their “own occupation.” However, most policies will change the eligibility for LTD benefits after a specific period of time, usually two years. At that point, the requirement to remain eligible for LTD benefits is that your disability prevents you from performing the essential tasks of “any occupation” that you could reasonably perform with training.
Contact a disability lawyer immediately if you receive notice that your benefits are being stopped.
The Insurance Company Has Evidence that Contradicts Your Claim
Insurance companies often employ investigators to conduct surveillance on long-term disability claimants and those already receiving benefits. That surveillance can include following the insured and taking pictures or videos of them when they leave their home, checking their social media accounts and running driver’s license and internet searches.
Their goal is to ‘catch’ you performing physical activities or hanging out socially in an attempt to prove that you aren’t disabled. Be mindful and assume you are being investigated. These investigations have led to people being wrongly accused of fraud based on video surveillance.
Which Option Should You Choose?
Appealing a Long-Term Disability Denial
There may be a situation when filing an appeal is the right decision for you. Possible scenarios include:
- Your condition has changed dramatically and you have compelling evidence that supports your claim.
- A typo or mistake is the only reason for the denial and you’re assured that fixing the error will result in an approval.
- You missed an appointment or assessment.
- You are finally able to get a report or some other documentation that wasn’t available for the first application.
- You didn’t comply with their requests for information on time.
- You didn’t meet with their doctor but are now willing to.
However, even if the reason for denial is one of the above, and you feel confident about the success of your appeal, unless you’re fairly early on in the process, filing an appeal is too risky.
The insurance company’s appeal can be a lengthy process. You may also very well end up having to see more specialists at their request, using up your Ontario sick leave to provide them with more information while they take their time, and send you through multiple levels of appeal until your time to file a lawsuit against them is gone.
It’s important to remember that Insurance companies are regulated by law so they are obligated to act in good faith and consider each claim for long-term disability benefits fairly. By providing clients with an appeals process, the insurance companies can argue that giving their clients a second chance is proof that their LTD claims process is fair.
The realities are:
- They are for-profit businesses and the more claims they pay out, the less money they make.
- The appeals are decided on by people working for the same company that denied your claim to begin with.
- An insurance company’s appeals process is unregulated, meaning they are set their own rules and procedures and have no oversight.
Filing a Lawsuit
In most situations, filing a lawsuit is likely your better option. Some of these scenarios include when your denial is based on:
- The decision that you are not disabled.
- A pre-existing condition.
- You failed their medical assessment.
- Evidence that contradicts your application.
- You missed the deadline to apply.
- You aren’t getting reasonable medical care.
Because it’s in an insurance company’s financial interests to deny as many claims as possible, hiring a lawyer and threatening them with a lawsuit is often the only way for someone who is legitimately disabled to receive the support they are entitled to.
When an LTD lawyer files a Statement of Claim against the insurance company, the claim will include:
- The benefits you should have received but were denied.
- The benefits you should have been receiving between the denial date and when the case settles or a trial is completed.
- Punitive damages if your insurance company acted in bad faith.
Many Canadians believe that even if they successfully sue the insurance company, it will take them years before their case finally resolves and there will be nothing left of the settlement.
The reality is that the vast majority of LTD lawsuits are settled in fairly short order. A long-term disability lawyer puts together a package of evidence that contradicts the insurance company’s reasons for denial and the negotiation process begins.