If you’ve suffered an injury that has sidelined you for a considerable length of time, you might be eligible to file a long-term disability claim. Unfortunately, these claims can be quite complex and are often denied by the insurance company involved. Read on for more information about your rights and potential next steps, and how to appeal a long-term disability denial.
What Is Long-Term Disability?
In Ontario, many workers have short-term and long-term disability benefits, which are designed to help them pay for everyday expenses in the event of a serious injury or illness. For both types of benefits, you will need to apply and get approved.
A long-term disability claim arises when a person suffers a personal injury that affects their ability to work, function, and live in the long run. Traumatic brain injuries, spinal cord injuries, various injuries suffered during an accident, psychological injuries, and mental health issues are just some examples of injuries that can lead to long-term disability claims. These types of injuries can impact your life in a serious manner, sending you from financial independence to needing long-term disability benefits.
Long-term disability involves insurance benefits that generally begin when other benefits from your employer, such as short-term disability benefits, have ended. The purpose of long-term disability insurance is to offset your financial difficulties if you lose your source of income, and often, the goal of this claim is to provide you with funds for bills and expenses, medical treatments, and rehabilitation costs.
What Are Some Common Reasons Disability Claims Get Denied?
There are several reasons an insurance company may deny your long-term disability claim. For example:
- Your claim may not meet the insurance company’s definition of long-term disability. Before filing a long-term disability claim, you will want to review your insurance policy and make sure you understand the conditions that make you eligible and fulfill the definition of disability used by the insurance company. Look for any excluded conditions, as well as the company’s definition of what constitutes a disability.
- There may be insufficient evidence to prove your claim. Whether it be missing medical records or a lack of detailed explanations by your doctor, if you don’t provide sufficient evidence to back up your claim, it is likely to result in a denial.
- You may not be receiving regular medical treatment, which is typically considered to be necessary by an insurer in order to strengthen your case. Lack of proper medical testing, imaging, and treatment at regular intervals can work against you in your long-term disability claim.
- There may be a procedural reason for the denial. For example, you may have missed a deadline or failed to communicate with the insurance company, causing them to reject your claim.
- Upon investigation, the insurance company may have discovered that you were acting against your doctor’s restrictions. It is common for an insurer to perform investigations and even video surveillance of long-term disability claimants. If you are found to engage in an activity that is inconsistent with your allegations of disability, your claim may be denied and any previously awarded benefits may be terminated.
What Should You Do if Your Claim is Denied?
If your claim is denied, you will have the right to appeal the decision. You should know, however, that a long-term disability denial appeal is not a formal legal proceeding; rather, it is a process used by the same insurance company that denied your claim. During this process, you present your evidence to the insurer, and there is no neutral decision-maker involved. This means that generally, long-term disability appeals rarely succeed.
You also need to be aware of the deadline to start an action against your long-term disability benefits insurer. You have 2-years from the date of your original denial to file a claim in court and not from the date of your last appeal. I caution people to be aware of the timelines as the appeals process can be long and dragged out, which is why it may be best to skip it entirely.
If your appeal is unsuccessful, you can file a claim in court to enforce your legal right to long-term disability benefits. Because this process can be complex and involved, the help of an experienced long-term disability denial lawyer can be invaluable. They can put together a strong case on your behalf, based on the evidence, and present that case in court. They can investigate the unique facts of your claim and preserve important evidence. They can communicate and negotiate with the insurance company in order to obtain a favorable and fair settlement.
Steps to Ensure a Successful Appeal
Should your long-term disability claim be denied, it may not be the end of the road. You may be able to appeal and still get your rightful benefits. However, to make sure your appeal is successful you must take the right steps:
- Read the denial letter. Your denial letter should explain that you were denied and why. Read through the letter carefully so you understand why you were denied. Keep your letter in a safe place and note any deadlines mentioned.
- Understand your disability policy. Your employer should have provided you with documents about your short-term and long-term disability coverage. These documents outline the insurer’s guidelines, explain how eligibility is determined, and explain what specific conditions are covered. You need to understand all of this and the regulations you have to follow during the coverage period and claim process to stay eligible for disability.
- Act quickly. Keep an eye on any deadlines the insurance company imposes. You may only have a short time to provide more information or to file a legal claim. Missing deadlines can mean you lose out on benefits that should be rightfully yours. If you are considering contacting a lawyer, you will want to do so as soon as possible so your lawyer can take steps to protect your rights.
- Consider what evidence you may need. Proving your disability means having the medical evidence to support your claim, and one of the most common reasons for denials is lack of evidence. In general, having test results, scans, and other objective evidence is best. Continuing to attend all doctors’ appointments and follow your treatment plan ensures you get more medical documentation. Your disability claims lawyer can also help you secure the medical evidence you need.
- Say “no” to the internal appeals process. While your insurer may offer this as an option, it’s rarely successful. Essentially, what is happening is that someone from the insurance company is looking at your claim after their co-worker has already denied it. They are unlikely to make a different decision.
- Contact a long-term disability lawyer. Trying to work with the insurance company yourself or trying to file a legal claim is complicated and this is something best left to an experienced lawyer.
The reality is that not everyone is taught how to file a disability claim, and the process can be complex. It’s easy to make mistakes. In addition, insurers have a financial motive to deny claims since the less money they pay to you the more they have in profits for their shareholders. All these factors mean that hard-working Canadians have their rightful claims denied.
If you get a denial letter after applying for long-term disability, act quickly and contact my law firm, Derek Wilson Injury and Disability Law.
When It’s Time to Find a Disability Lawyer to Help
If you’ve been denied short-term disability benefits, you may want to contact a short-term disability lawyer to get support. Short-term disability is designed to help you get benefits quickly, so contacting a lawyer fast is important.
If you’ve been denied long-term disability benefits, you’ll want a lawyer who has experience with successfully appealing these kinds of cases. Long-term disability denials are unique because they tend to involve more complex medical conditions and illnesses than short-term disability claims, and insurance companies can be more aggressive in trying to deny a claim.
In this situation, you’ll want to contact a long-term disability lawyer as soon as you get your denial. Bring your denial letter with you. Even if you’re not sure you can get your benefits or aren’t sure what a lawyer can do for you, get legal advice as soon as you get that denial letter.
There may even be situations where you want to contact a disability lawyer before you’re denied. If the insurance company is acting in bad faith—if your relationship seems to be getting adversarial, if the company isn’t responding to your communication, or if you get a sense your claim will be denied—contact a disability claims lawyer.
There are many things an experienced disability claims lawyer can do for you. A lawyer can:
- Explain the insurance documents and denial letter. These documents may contain complex language that is confusing. You may think you’ve met all the requirements of your application or claim, but if they’re written in complicated legal language, you may have missed crucial details.
- Explain your options. A lawyer can look at your situation and explain whether you can appeal, what steps you should take, and the strength of your claim. That way, you can make the right decision.
- Represent you. If you decide to pursue the benefits you deserve, a lawyer can be essential to proving your disability, negotiating with the insurer, and taking care of all the details that come with addressing a denial.
Even if you do get long-term disability benefits, you may wish to contact a disability claims lawyer if you run into problems. It’s common, for example, for an employer or insurance company to try to force an injured worker back to work before a doctor clears the employee. If this happens to you, contact a disability claims lawyer immediately.
In these situations, an employer may claim they can’t accommodate your injury. Or, an insurance company may try to claim you’re recovered enough to return to work or to return to modified duties. This is serious because returning to work before you’re healed can mean re-injury or major complications for you. If you feel pressure from the insurance company or your employer to return to work that doesn’t fit with what your doctor has said you can handle, contact a disability claims lawyer as soon as possible.
How Can Derek Wilson Help Maximize Your Chances of a Successful Appeal?
Not only have I successfully represented many clients with long-term disability claims, but for over a decade prior to that, I worked for insurance companies, which helps me uniquely understand what insurance companies are looking for and what makes a long-term disability claim strong. I will focus on presenting your claim for long-term disability insurance benefits in a way that meets the requirements of your specific policy, demonstrating the full scope of your damages and unique situation.
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.
