Disability Insurance Claim Denial

Have you had a disability insurance claim denied? Derek Wilson is an experienced disability insurance denial attorney in Hamilton who assists disability claimants across southern Ontario. A disability, whether sudden or degenerative, can leave you with lost income and unable to pay for your living expenses. It’s a scary and often frustrating position to be in, and most people — if they have insurance — look to their disability insurance policies for hope and help moving forward. Making an insurance claim may seem straightforward, but unfortunately, it is not always so. 

Can Disability Insurance Be Denied?

We see both long-term disability (LTD) claims, and even short-term disability claims, unfairly denied often by insurance companies on simple technicalities. Read on to learn more about how a long-term disability insurance denial attorney can help. 

Why Was My Disability Claim Denied?

There are several common reasons why your disability claim may have been denied. It could be that the claim did not include proper medical documentation that was required by the policy or the injury/illness didn’t meet certain policy requirements. There are even times when claims are denied because the claimant may have missed a deadline. Let’s face it — the application process for disability benefits can be an extremely complex and time-consuming process.

• Lack of objective evidence: Claims reviewers sometimes deny disability claims, stating that there are no objective findings to support them. What this means is that the reviewer does not have hard data, such as x-rays, lab results, MRIs, or other medical tests in order to support a physical or mental health diagnosis. In some cases, a claims reviewer will use a lack of objective evidence as a reason to deny your claim even though this is not a requirement in your insurance policy. In that case, you may need to get help from an attorney who is experienced with denied disability claims. Some insurance companies have even been known to demand “objective evidence” where the policy does not actually call for it. 
• Pre-existing conditions: Some insurance companies will try to deny a claim based on a condition or symptoms that existed when your policy was not effective. For example, they may justify the denial with evidence that you have received treatment during a time period of exclusion listed in your policy. They may also deny claims if the reviewer indicates that you should have already sought reasonable treatment for a non-treated condition. However, just because this is a valid reason for denial in many policies does not mean that your claim is accurately lumped into this category, and this kind of denial should always be reviewed further.
• Change in plan’s definition of disability: In many policies, a predetermined change in the definition of disability as time goes on is used by insurers to give themselves an easy way out to discontinue benefit payments to otherwise eligible people. For example, most LTD insurance policies have a limited amount of time that a claimant can be paid when they can no longer perform their regular employment tasks. Once this predetermined time period — usually two years — is complete, the insurance company will only continue to provide coverage when you cannot work in any occupation. 
• Lack of appropriate medical treatment: Generally all policies require that people receiving disability benefits receive ongoing medical treatment, but there is a catch. If the policy does not define “ongoing care” but requires it, then the insurance company can always say you have not been receiving appropriate ongoing care. In some cases, insurers may not accept certain kinds of doctors as appropriate, or they may make recommendations for the care they will later use to deny a claim. 
• Surveillance: Insurance companies often hire private investigators to watch, follow, photograph, and film someone who has filed a big claim. They may also interview your neighbors, former co-workers, and other people you regularly interact with in order to see if your claim is fraudulent. When you are being honest with the insurance company and your doctors, you have nothing to worry about from their surveillance. Remember that having a disability does not mean life stops — in fact, almost 40% of the Canadian population aged 15 years and over with a disability is considered to have a “mild” disability. 

Am I Eligible for Disability Benefits?

If you have an LTD policy, either through your work or a private policy that you’ve purchased because you’re self-employed, there are a few things you should review in your insurance contract to check your eligibility under your policy and current circumstances. Your policy will have one of several ‘tests’ to determine when you might be eligible for disability insurance coverage:

• “Own Occupation” test: This definition basically states that you are eligible for benefits if you are not able to return to the exact job you had before your accident or the onset of your disability. A policy with this test and no time limit as to how long it applies is probably the costliest, but it also might be a good policy for those with specialized jobs. In these cases, many people who become unable to perform in their specialized occupations end up taking a major pay cut if they have to work in another field.
• Percentage test: This definition outlines a specific percentage of your duties that you are unable to do that qualify you as being disabled. For example, if you cannot do 65% of your prior duties, you would be considered as being disabled.
• “Any Occupation” test: This definition is the strictest of the eligibility tests. It means that your injuries are severe enough that you are unable to work in any occupation for which you are reasonably suited, taking into account your work experience, education, training, and previous salary.

How Do I Fight an Insurance Claim Denial?

Denied disability insurance benefits are very common in the insurance industry. If you have received a denial letter, here is what you can do.

1. Put your denial letter in a safe place. This is an important document because it will include the date of the letter, and in Ontario, this is the date from which the 2-year limitation period to sue starts to run. Your denial also includes the definition of “disability” as per your policy, the provisions of your policy, the insurer’s reasons for denying your benefits, and in some cases the last day of your long-term disability payments.
2. Skip the internal appeal process: It’s very difficult to win an internal appeal. Essentially, someone from the same company who already denied you is reviewing a co-worker’s previous decision. Unless you have brand-new information or medical reports to present containing information the insurer did not already have, it can be very difficult to win the appeal. It does happen, but it’s very difficult, which is why many people choose to retain a disability lawyer.
3. Read your policy or the policy booklet provided by your employer. Much of the information may be difficult to understand, but being informed can only help you. Look for any information that stands out to you, and make note of any questions you have that you can ask when you contact a long-term disability insurance attorney. 
4. Be aware of deadlines. These might be deadlines imposed by the insurance company with regard to providing more information for your claim or taking legal action. If in doubt about these deadlines, ask. In any situation in which your LTD benefits have been denied or terminated, you should speak with a lawyer who has experience in handling LTD claims as quickly as possible before making any decisions about your claim. 
5. Call a disability lawyer: The moment you receive your denial letter is the time to call a personal injury lawyer who has experience in long-term disability insurance in Ontario. Even if you are fairly confident you understand the reason for your denial, it can get complicated. For example, your policy may have rehabilitation care requirements written in complicated legal language that you thought you were meeting but have fallen short of because of understandable confusion. Having someone on your side who is looking out for insurance company tricks can be helpful. 
6. Keep seeing your doctor: Have them update your medical information. You will need your ongoing medical records to support your disability claim, and your doctor will also refer you to specialists. These specialists can help diagnose your condition, provide treatment options, and serve as expert witnesses in your case if needed.
7. Document conversations in writing. Even if you just send a quick email to yourself with a recap of a doctor’s appointment, phone call from the insurance company — which will hopefully be handled by your lawyer from this point — make sure to document dates, times, people, and important information. 

How Do I Write an Appeal Letter for Long-Term Disability Denial?

You can always appeal your denial directly with the insurance company, but a lawyer can help you save crucial time in getting back on track. Skip the internal appeal process, it’s very difficult to win because essentially someone from the same company is reviewing a coworker’s previous decision. Unless you have brand new information or medical reports to present containing information the insurer did not already have, it can be very difficult to win the appeal. It does happen but it’s very difficult which is why many people choose to retain a disability lawyer

You do not even have to wait until you are fighting a denied LTD claim to seek legal help. Even if you have not yet been denied, you may be getting a sense that receiving benefits under your long-term disability plan is becoming more complicated than seems reasonable. Hiring a lawyer can help you make sure that you are staying on top of your own deadlines, paperwork, and any other eligibility requirements in order to build the strongest claim possible. 

How Can a Long-Term Disability Insurance Lawyer Near Me Help?

Derek Wilson Personal Injury Law can help you navigate your long-term disability benefits case. Insurance companies and long-term disability policies in Canada can be complex to navigate on your own, which is why our team is prepared to take all reasonable steps to proceed with your claim and get you fair compensation. We are passionate legal professionals and have assisted many individuals across Ontario in recovering fair settlements. We are happy to discuss with you the strategies we have used in our appeals cases that insurance companies approve. Disability claims are not hopeless.

Personal injury law is different from other types of law because we only get paid if you get compensated for your injury damages. This structure is called a contingency fee, and many personal injury lawyers work on a contingency fee. This is generally a good thing. For one, it means you can expect that any lawyer who takes your case is confident they can build a strong claim. It also means you are not out any money to your total permanent disability insurance lawyer if your claim is less successful than you hoped. However, you do need to account for the legal fees when considering the final settlement amount you can expect to receive. Understanding the contingency fee process is important, and you should be prepared to ask any lawyer you speak to about their fee arrangements. 

My firm focuses only on personal injuries and represents clients with long-term disability claims. We provide fair and honest legal advice with a focus to help clients recover fair compensation with no up-front fees. Call us at 855-769-0418 or get in touch online to schedule a free consultation.

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