According to The Centre for Addiction and Mental Health (CAMH), by the age of 40, one in two Canadians will have had a mental illness or will be dealing with an ongoing mental health condition. When these conditions leave Canadians unable to work, short-term and long-term disability benefits from employers or group plans can be a financial lifeline.
Unfortunately, even though Canadians diligently pay premiums on short-term and long-term disability benefits, they don’t always get the benefits they expect. Employees dealing with mental health disabilities sometimes find their claims unfairly denied.
If this happens to you, contact Derek Wilson Injury and Disability Law for a free consultation. Let’s talk about why you were denied and what you can do to get your benefits.
Mental Health Disabilities
Mental health disabilities can include a wide range of conditions, with symptoms that vary from mild to debilitating. Common mental health disabilities which may be covered by your disability coverage include:
- Depressive disorders
- Anxiety
- Obsessive-compulsive disorder
- Attention deficit disorder (ADD) and attention deficit hyperactivity disorder (ADHD)
- Post-Traumatic Stress Disorder (PTSD)
- Chronic stress
- Eating disorders, including anorexia and bulimia nervosa
- Bipolar disorder
- Somatic disorders, including conversion disorder, body dysmorphic disorder, and somatoform disorder not otherwise specified
- Schizophrenia
Any mental health condition that affects the function of your mind could impact your ability to perform your work duties. It is very similar to a physical disability in that it prevents you from handling tasks you need to perform in the workplace. Just like a physical disability, continuing to work with a mental health disability against doctor’s orders can put you at an increased risk of complications and a poor prognosis. That’s why it’s important to treat your mental health seriously and to get the resources you need to take time off work if you need it.
How Claims Work with Mental Health Conditions
In Ontario, if you have a diagnosed mental health disability, you may qualify for long-term or even short-term disability, though this will depend on your policy. In addition, according to the Ontario Human Rights Commission, your workplace must accommodate your diagnosed mental health condition.
In order to get disability benefits, you first need to review your group policy or employer’s disability policy to understand what conditions are covered and what your coverage includes. Some policies exclude specific mental health conditions. In general, though, you must be able to prove that your mental health condition prevents you from working based on your diagnosis, medical records, and other evidence.
Soon after your diagnosis, you may be eligible for paid vacation, sick leave, or short-term disability benefits, which can provide you with income and benefits while you recover. There is a period outlined in your long-term disability policy during which you can’t access long-term disability. This period can be 13 to 26 weeks. During this time, you will rely on other benefits. After this period, if your health condition continues, you will be eligible for long-term disability benefits.
Benefits for mental health conditions are calculated the same way as for physical benefits. Depending on your insurer, you may be eligible for up to 60-70% of your monthly income with long-term disability.
Potential Problems and Reasons for Denials
One thing you need to be aware of is that getting your rightful benefits for a mental health condition can be far more challenging than getting benefits for many types of physical conditions. This is for a few reasons:
- There are few diagnostic tests. With a broken bone, you can submit copies of x-rays to your insurer to show the fracture. There are no definitive tests that objectively show a mental health disorder, which means that you must report symptoms to an experienced doctor, who can then provide a diagnosis.
- Mental health conditions vary widely. One patient with a diagnosis of depression, for example, may be able to work while someone else with the same condition may not be able to. This can make denials more likely.
- Some conditions may be episodic. Insurance companies will sometimes use investigators or other means to check up on employees who are getting benefits, to verify whether they are injured. With mental health conditions, however, an individual may be incapacitated but may experience a reprieve from symptoms for a few hours or a few days. While they may still be unable to work, the episodic nature of the condition can lead to denials of benefits.
- There’s still a stigma about mental health. The stigma surrounding these conditions can make it difficult for employees to seek help. Some may not want to share their diagnosis with an employer. While this is understandable, it can also keep employees from getting the help and support they need.
These challenges can mean you need to build a strong case. Working closely with medical professionals, following their treatment plan, and following up with your doctor or mental health professional can help you document your condition, which can help you get the benefits you need.
When speaking with mental health professionals and doctors, it’s important to get an assessment of functional impairment as well as a diagnosis. Insurance companies want to know what medical condition you have, but also how it impacts your ability to perfect the essential tasks at your job.
An experienced physician can help because he or she can fill out a medical report that focuses on functional impairment. It can also be useful to get a referral to a psychiatrist, who can speak with more authority about how your medical condition can impact your ability to work.
It’s especially important to speak with a psychiatrist because misdiagnosis rates for psychiatric disorders are 66-98% in Canadian primary care, according to a research paper by Dr. Diane McIntosh. In other words, most patients who seek mental health diagnoses from a primary care doctor in Canada are initially misdiagnosed.
In Ontario, you need to be referred to a psychiatrist by a family doctor. If, like many Ontarians, you don’t have access to a family doctor, you may need to use a walk-in clinic and ask for a referral to a psychiatrist. Try to get copies of your medical records, too, so you can show you spoke with someone and are at least on a waiting list for a family doctor and psychiatrist.
Whether you have a family doctor and psychiatrist or not, it can be useful to keep a written record of your medical condition and how it affects your ability to work. This helps you track your experience, which can be useful for your doctor or psychiatrist, allowing him or her to see the extent and severity of your symptoms, which can help with a diagnosis. While your own notes aren’t enough to use as proof with the insurance company, they can help you in discussions with your doctors and with your short-term or long-term disability claims lawyer, ensuring you stay clear and accurate in your descriptions of your symptoms.
Before and during your claim, it’s also important to follow your healthcare providers’ treatment plans. Most long-term disability policies mandate that you take part in treatment and are under the ongoing care of a medical provider while you get your benefits. Gaps in treatment could jeopardize your benefits.
Attempting all recommended treatment plans, seeing your doctor regularly, and getting your treatment adjusted as needed shows you’re taking your condition seriously. It also ensures your treatments and condition are properly documented since every time you take part in treatment or visit a medical professional there is a record of your visit.
If you are having trouble getting the care you need, you may also want to seek a second opinion. Even if one doctor or psychiatrist doesn’t help, another healthcare professional may have a different opinion—and that opinion could help you get the treatment and benefits you require.
Generally speaking, lack of objective evidence is a top reason for the denial of long-term benefits, and that’s especially true when the medical condition concerns mental health. The more you visit doctors, keep track of symptoms, and take part in treatment, the more evidence you gather of your disability, which can help with your claim.
It can be frustrating to continue seeking medical care, especially for mental health disorders. It’s not unusual for patients to have to seek multiple care providers before getting the right diagnosis, and it can take trial and error to find the right medication and treatment plan. Despite the frustration and the delays in the Ontario health system, it’s important to persist so you end up finding a treatment that works and get access to the benefits you need.
What Should I Do If My Claim Is Denied?
Unfortunately, legitimate disability claims are denied all the time. Your short-term or long-term disability claim may be denied when you first apply for benefits. Your benefits can also be terminated for a few reasons, even once you start to get benefits.
A common thing that happens with long-term benefits, for example, is that the insurance company will claim that you are ready to return to work—even if your doctor disagrees. You may even feel pressure from your employer to return to work duties, especially if your workplace can’t or won’t accommodate your disability. It’s not unusual in this situation for the insurance company to request a medical exam, which could be used as a basis for stopping your benefits.
The stress of being diagnosed with a mental health condition and undergoing treatment can be made worse with a denial or an adversarial situation where the insurance company seems to be seeking to stop your benefits.
Insurers are required to inform you of a denial by letter, and if you receive a denial letter, review it carefully and keep it in a safe place. Your denial letter will outline why your claim was denied. The most common reasons may be because:
- You didn’t seek medical attention.
- You didn’t continue to follow treatment recommendations.
- The insurance company feels there isn’t enough medical evidence of your condition.
- Your medical records, statements, and other documentation are inconsistent or contain errors.
- You missed deadlines or important details when applying.
- The insurance company doesn’t think you are being accurate in your depiction of your condition and feels you can perform work duties.
Whether you understand the denial or not, you’ll want to keep the letter safe and contact a disability lawyer. Bring the denial letter with you to your consultation with a lawyer so your lawyer can review the letter and explain your potential next steps.
Your insurance company will give you the option of an internal appeal, but this is rarely successful. In an internal appeal, it’s the insurance company reviewing their own decision. Chances are, they will only reaffirm their denial, and they will just use up time doing so—time you could have used to seek your benefits.
A better option for many employees is to file a claim against the insurer. Working with a long-term disability or short-term disability lawyer means your lawyer negotiates with the insurance company and prepares a court case for you. Your lawyer seeks a fair settlement and, if one can’t be reached, presents your case before the courts. For many employees, this is the path that ultimately leads to getting the benefits they deserve.
Contact Us for a Free Consultation
Have you been denied your rightful disability benefits? Are you worried about how you’ll pay the bills when you’re not getting the benefits you’ve been relying on? Contact Derek Wilson Injury and Disability Law for a free consultation with Derek Wilson, who has 30 years of experience getting fair benefits for hard-working Ontarians in Hamilton and surrounding areas. In a free consultation, Derek Wilson can answer your questions and explain your options if you’ve been denied benefits.
