Many Canadians pay costly premiums for long-term disability insurance, so it can be incredibly surprising and depressing when you file a claim only to have it denied. The unfortunate truth is that denials of benefits are extremely common, but you need to understand that you will still have options even after an initial denial.
In most cases, insurance companies are certainly hoping that you will receive your denial letter and conclude that is the end of the road, because that will allow the insurer to save significant sums of money. However, appropriate action can help you obtain the benefits that you need and deserve.
Why Are Long-Term Disability Claims Commonly Denied?
There are several different reasons why insurance companies deny long-term disability benefit claims. Following are some of the most common reasons for denials:
- You are not “totally disabled.” Many insurance companies will conclude that an applicant does not satisfy its definition of “totally disabled,” using that as a reason for denying a claim.
- The insurer disagrees with your doctor that you can’t work due to disability. In some cases, the insurance company will simply disagree with the opinion of your doctor that you have a disability that keeps you from being able to work, and may cite other reasons why you should be capable of working.
- There is a lack of supporting medical documentation. Many applicants are denied for failing to include all of the necessary medical paperwork proving their disability.
- There is no diagnosis for your disability. Some people apply for disability without ever seeing a doctor, and these cases are among the easiest for insurance companies to deny because they will use the lack of medical confirmation as evidence of a lack of disability.
- You can work in another occupation. An insurance company may claim that even if your disability prevents you from returning to your normal line of work, you are still capable of working in another profession.
- You have not complied with recommended treatments. Doctors will advise patients to take certain steps to improve their conditions, and insurers will use private investigators to determine that these steps are being followed. Failure to follow a doctor’s advice can be deemed a reason for denying a disability claim.
- You applied too late. You only have a limited amount of time to apply for long-term disability benefits and failure to apply within the appropriate window will usually lead to an automatic denial of benefits.
- Surveillance contradicts your claim. Again, insurance companies invest heavily in private investigators who will use both video and social media surveillance to uncover all kinds of proof that you are not as disabled as you claim.
- Independent medical examination says you are not disabled. The independent medical examination (IME) is used by insurance companies to get medical opinions from their own selected doctors, as opposed to the one you regularly see.
- You refuse to go back to work or to participate in a gradual return to work program. Even though you may be too weak or in too much pain to return to work, an insurer could fault you for not making more of an effort to return to work when it believes you are capable.
- You are in breach of some provision of your long-term disability policy. Your insurance policy is based on a contract you(or your employer) signed with the insurer, and there is often language contained to specifically limit what the company will have to pay. Pay special mind to areas such as subjective conditions and conditions expressly excluded under the policy.
- You are not covered because of a pre-existing condition. Insurance companies often have language in their contracts allowing for denial of claims when there is evidence of pre-existing conditions, so disabilities in which pre-existing conditions are factors are commonly denied.
- You have not sought out accommodations or alternate work. Insurance companies may look to see if you tried to seek any accommodations in your own role at work before you stopped working. The insurer will also look to see if you made any attempts to work at a different kind of job that may be more suitable given your limitations. Whether it is lighter duty, another kind of occupation, or a reduction in hours worked, the insurance company wants to see that you tried all possible avenues before it can conclude that you are completely unable to work.
What Should You Do Post-Denial?
In most every case, it will be in your best interest to immediately consult with long-term disability denial lawyers so you can determine what your best options are moving forward. An experienced long-term disability claim denial lawyer will know how to file a claim and also give you a better chance of being successful.
Another good immediate step to take upon being informed of a denial of long-term disability benefits is to determine how long you have to sue. In most cases, it is two years from the date of the initial denial
You may have to deal with your employer initially too, since they are going to be notified by the insurance company that your claim was denied and you should be able to return to work. You may have to get a note from your doctors stating that you can’t return to work.
You will also need to gather a number of important documents, including the denial letter from your claim representative, a copy of your group insurance booklet describing your long-term disability benefits, a copy of the insurance company’s “claim file”, your union’s collective agreement when applicable, and a copy of medical file going all the way back to when your symptoms started to affect your work.
As soon as your claim for Long Term Disability benefits is denied by your insurer you shouldn’t sit back and wait. You need to act and prepare for what may come next by getting a long-term disability denial law firm on your side.
Should I Appeal?
If your claim is denied, you have a few options. One of these is to seek an internal appeal. This is not a formal legal proceeding. In an internal appeal, a person from the same company that denied your claim reviews the documents related to your claim. They’re effectively looking at their co-worker’s decision, so they’re likely to come to the same conclusion as their colleague.
An internal claim is not neutral. It is conducted by the same insurer who has already denied your claim, and that insurer has a financial interest to be conservative when reviewing claims. The more money an insurance company collects in premiums and the less the company pays out, the more profits they have for shareholders.
Internal appeals are also time-consuming, and you may not have extra time to wait if you can’t work or earn an income. It can be especially difficult to wait, knowing that most internal appeals are not successful for the reasons mentioned above.
An appeal may only make sense if you have significant and entirely new information about your medical condition that you didn’t have before. Even in that situation, it can be best to work with a long-term disability lawyer. A lawyer can explain whether an appeal makes sense for you and can work to prove your disability.
What’s the Alternative to Appealing?
Since appeals usually don’t work, you may be interested in other ways to get your rightful benefits. One option is to file a claim against the insurer. You generally have two years from the date of your denial (not from the date of your appeal) to start an action by filing in court.
It’s important to take note of this deadline and to consider consulting with a long-term disability benefits lawyer as soon as possible since the appeals process can take a long time. If you’ve chosen to appeal, by the time you’ve exhausted all your appeals and the process has ended, you may be coming up against that two-year deadline.
A legal action against the insurance company involves filing your claim in court, presenting the right evidence in accordance with legal rules, and presenting your case in court. An experienced long-term disability lawyer can do this on your behalf.
Another alternative to an appeal is seeking a settlement. This is where your long-term disability lawyer negotiates with the insurance company to come up with a fair settlement offer. The settlement can take place as you file a claim so if a settlement doesn’t work, you may still have the ability to present your case before a court.
A big advantage of setting a settlement is that once the insurance company has paid the settlement, that’s it. You don’t have to worry about getting your benefits cut off, you don’t have to continue to abide by the terms of the insurance company’s terms of policy, and you don’t have to worry about the insurance company sending you to additional insurer medical examinations. You and the insurance company can walk away, and you have the resources you need to pay your bills.
It’s hard to overstate how important this is. While you’re receiving long-term disability benefits every month, you have to play by the insurer’s rules and follow all the terms of the policy. You need to visit the doctor, submit additional information as per the insurer requirements, and meet all the requirements of the policy. Behind the scenes, the insurance company may even be working with an investigator to determine how injured you are. You’re vulnerable because you rely on those benefits and they can be denied or can be cut off once you’ve been receiving them.
For this reason, a settlement can be a good choice because it represents a clean break from the insurance company. For example, let’s say that you receive long-term disability benefits, but then the insurance company sends you to a medical examination and decides that you are fit to return to some kind of work—even though your own doctor feels that doing so is unsafe. You may be in danger of losing your benefits, especially if your employer can’t accommodate you or if you can’t, in fact, safely return to work.
In this situation, your lawyer can negotiate for a settlement. Your lawyer can present evidence of your injury and speak to the insurer on your behalf, so you don’t have to. If you are successful in securing a settlement, you can skip the claim against the insurer, and you will have resources to pay for your life. You can focus on your health.
Another benefit of seeking a settlement is that settlement funds for future long-term disability benefits aren’t taxable. Your monthly long-term disability benefits are taxable, and with Ontario’s high tax rates, you can save a significant amount by pursuing a settlement rather than monthly benefits. While this depends on your situation, the tax advantage can mean your settlement dollars go further than monthly LTD payments.
If you’re not sure what option is best for you, a long-term disability lawyer can review your options to discuss whether an appeal, settlement, or claim may be the best option. Your lawyer can explain what you can expect, can answer your questions, and can represent you as you seek your rightful benefits.
What Can I Expect If I Decide to Pursue a Settlement?
While every case is different, there is one thing that may be a pleasant surprise: While many personal injury claims in Ontario can take two years or more, on average many workers get a settlement in about a year. While there are no guarantees, these claims tend to be shorter.
On the other hand, you can expect the insurer to try to claim that you are not injured at all and aren’t entitled to any settlement, which is why working with an experienced long-term disability lawyer is important.
A lawyer will work to determine how much you’re entitled to and will begin with the maximum fixed amount noted in your policy, calculating the amount you’d receive up to age 65. Your lawyer will also consider the severity of your disability or injury and other contingencies when negotiating on your behalf and building your case.
Filing a claim and seeking a settlement both involve gathering and securing evidence, filing the right paperwork, keeping an eye on deadlines, reviewing medical reports, arranging meetings with insurers, negotiating, and more. Big insurers have teams of experts taking care of all of this, so you don’t want to try to DIY your own claim. Working with a long-term disability lawyer is important to make sure you don’t make a mistake that costs you your benefits.
Should I Sue if I’m Denied?
Every denial is different, and trying to decide on your own whether you should sue or appeal is challenging. Deciding to file a claim is based on many factors, including:
- The strength of your claim and the evidence you have of your injury or disability.
- The insurance company involved.
- Your financial situation.
- Any pre-existing conditions you may have.
- Your disability policy.
- The accommodations, if any, your employer is willing or able to make for your disability.
- The severity of your disability.
- The reason for the denial.
The decision you make about seeking an appeal, settlement, or claim can have a significant impact on your financial future for years to come. If you don’t get your rightful benefits, you may need to rely on savings or even liquidate assets to pay your bills while you can’t work. Even after you have recovered, the loss of those assets and savings can be challenging for your financial life. In addition, without your rightful benefits you may feel pressure to return to work before it is safe to do so, putting you at risk of complications or re-injury, which can make your health situation much worse.
The stakes are high, which is why you’ll want to speak to a disability claims lawyer. An experienced lawyer has seen cases similar to yours and can speak to what you can do. A lawyer can also create a customized plan to help you seek the benefits you deserve.
You don’t have forever to decide, and deadlines can sneak up on you. Speaking to a lawyer doesn’t mean you have to hire one, so speak to a lawyer as soon as you get a denial letter or as soon as you start getting letters from the insurance company indicating your benefits are at risk. The sooner you get a lawyer involved, the sooner you get an opinion about your situation so you can make the right decision for you.
How Can Derek Wilson Injury and Disability Law Help?
Derek Wilson has more than 25 years of experience handling long-term disability insurance claim denials. He knows how to help clients recover the compensation they are entitled to.
Furthermore, he handles every single case himself and never delegates his cases to any junior lawyers. Perhaps the biggest benefit of working with Derek Wilson Injury and Disability Law is his previous experience working for insurance companies; he knows all too well how insurers act in these situations and he can anticipate what actions they will take.
Derek Wilson has helped countless clients throughout the Ontario area who had long-term disability benefits denied. He handles cases in such areas as Milton, Mississauga, Kitchener, Brantford, Guelph, Oakville, St. Catharines, Niagara Falls, Cambridge, Burlington, Welland, Brampton, Stoney Creek, Grimsby, Hamilton, and Lincoln.
You will not be asked to pay anything up front because he works on a contingency fee agreement, meaning that you only pay when you get paid. Call us at 289-274-9567 or toll-free at 1-855-769-0418 or complete an online contact form to schedule a free consultation that will allow us to sit down with you and go over all the details of your case so you can know exactly what your rights are and what we can do.
