Kitchener Disability Lawyer

When you’re injured or ill and unable to work, you’re at your most vulnerable. You may be worried about paying for necessities, concerned about your health, and fretting about the future. If you’ve been paying for short-term or long-term disability benefits, of course, you expect the insurer to be there in your time of need. Unfortunately, in Kitchener, many policyholders find that their claims are denied, even when they have legitimate claims.

When you receive a denial letter or get the sense your insurer is planning to cut off your benefits, don’t hesitate. Contact a Kitchener disability lawyer because this is not a situation you can take on yourself. Contact me at my law firm, Derek Wilson Injury and Disability Law, for a free consultation.

Understanding Disability Claims and Benefits

In Ontario, if you have an injury or illness that keeps you from working, you may be covered by disability benefits, workers’ compensation, or some government benefits, such as Employment Insurance (EI) Sickness Benefits or Canada Pension Plan disability benefits. Many workers in Kitchener, for example, pay into a group short-term and long-term disability plan or secure this type of coverage through their employer as part of a benefits package.

When you apply for disability, you’ll generally apply for short-term disability first. This coverage is designed for conditions from which you’re expected to recover within a few months — though some generous policies can cover you for up to a year. Short-term disability will compensate 60% to 100% of your income, depending on your policy.

Long-term disability, as the name implies, is for longer-term conditions, such as paralysis or a chronic condition that prevents you from returning to work. These policies vary widely. Some cover you for a few years, while others last until your retirement. Some long-term benefits cover 60% to 80% of your income, and some have a monthly cap, regardless of your income.

Navigating the Disability Claims Process

In Ontario, you may have several options, so the first step is to figure out which benefits are appropriate in your situation. For example, if you don’t have short-term or long-term disability coverage, you may qualify for a government plan. If your injury was sustained at work, you may qualify for workers’ compensation, which pays up to 85% of net pre-injury earnings and also pays for needed medical care that’s not covered by the Ontario Health Insurance Plan/Assurance-Santé de l’Ontario (OHIP).

Your employer may also offer sick leave. If that’s the case, you may need to use up your sick days before you apply for disability benefits. When you do apply for disability, you will need to do the following:

• Review your policy. Read the documentation you received from your employer or group plan carefully to determine whether you qualify for benefits and to understand the application process, which is slightly different with every insurance company.
• Inform your employer. Tell your employer about your injury or illness as soon as possible. Your company can provide you with forms and instructions about how to apply for benefits.
• Work with your doctor. You will need to visit your doctor (or a walk-in clinic if you don’t have a family doctor) to get a diagnosis and treatment plan. Your doctor will need to fill out documentation, too, and will need to supply you with medical evidence, such as test results, that you can send to the insurance company.
• Submit your application. Fill out your application carefully since even a minor mistake can lead to a denial. Fill out every section and double-check your work. Make sure that you describe the medical condition or injury exactly as the doctor explained it to you and as it appears on your medical documentation.
• Wait for the decision. If you’re applying for short-term disability, you may get a decision within 10 business days, though it can take longer. With long-term disability, it can take three months or longer to hear back. At any point in the process, you may be contacted by the insurance company for additional information.

No matter how much you have cooperated with the insurer, how much additional information you have sent in, and how carefully you followed all the instructions, you may still be denied benefits. In this situation, working with a Kitchener disability lawyer can help you pursue your rightful benefits.

Eligibility for Long-Term Disability Benefits

To be eligible for long-term disability benefits, the insurance company will look at how your specific condition affects your ability to work. The company uses specific “tests” to define whether you’re eligible. For example, if your policy is based on the “own occupation” test, then the insurer will be looking at whether you can return to your specific job. If you can’t, then you may be eligible for benefits.

For a policy based on the “any occupation” test, disability is defined as the inability to return to any job for which you may be qualified. For example, if you have project management experience in a warehouse but can’t return to that job, the insurer may still think you are qualified to do remote project management work for a different industry. In that case, your claim could be denied.

Some policies also use a percentage test to determine whether you’re disabled. For example, a policy may say that if you can’t perform 70% of your work duties, you are considered disabled and qualify for benefits.

Common Reasons for Denied Claims

Even if you think you’re eligible for disability and do your best to fill out all the forms correctly, you could be denied, and it’s not always your fault. Some common reasons for denial include:

• Not enough medical documentation. Lack of medical evidence is the most common reason for denial of disability benefits. The insurer may claim that the documentation you submitted didn’t prove the disability or failed to show how your medical condition prevents you from doing your job.
• Not continuing medical care. Most policies clearly state that you need to get “appropriate ongoing care” for your condition to continue to be eligible for benefits. Your benefits can be cut off if you stop following doctors’ orders. However, you can also run into trouble if you can’t get appropriate care because there is a long waitlist to see the appropriate specialist or if you’re having trouble getting access to care because of the doctor shortage.
• Surveillance. Some insurance companies hire private investigators to check up on your activities and use the results to try to deny your claim or cut off your benefits. For example, if an investigator photographs you mowing your lawn, the insurance company may try to deny your claim. An experienced lawyer can gather evidence to show that even if you can mow the lawn, it doesn’t mean you can perform the core duties of your job.
• Change of disability definition. Even if you have been receiving long-term disability benefits for months or years, most policies allow insurers to change the definition of disability, usually after about two years. Insurers will then look to see if you can perform “any occupation” and may try to cut off your benefits by claiming you can do different work at a reduced capacity.
• Application errors. If you miss deadlines for submitting documents, fail to submit all required documents correctly, or don’t describe your condition consistently, your claim will usually be denied. Any small error with your application, whether it’s failure to include a pre-existing condition or failure to submit additional information by the insurer’s deadline, will result in a denial.

No matter why you have been denied, an experienced Kitchener disability lawyer knows how to make it right. Whether the insurance company is acting in bad faith or whether there is another problem, consult with a lawyer who can explain what you need to do next.

Why You Need a Disability Lawyer in Kitchener

One of the challenges with getting a denial letter from an insurance company is that you may not know exactly why you were denied benefits. The letter may explain some of the reasoning, but it’s not always clear. A Kitchener disability lawyer can take a look and explain the problem in plain English.

Moreover, your lawyer can see what you can’t see. For example, if your doctor made a mistake on the documentation, failed to refer you to a specialist, or didn’t order the tests an insurer wanted to see, a lawyer can determine the problem and take steps to address the issue without harming your working relationship with your doctor.

Many patients in Kitchener also have a hard time getting medical evidence to build a strong claim because they’re on the waiting list to see a specialist or to get diagnostic tests. A Kitchener disability lawyer understands the local challenges and knows how to get the medical evidence you need for your claim.

Another reason you need a disability lawyer in Kitchener is that you want someone to interact with insurance company representatives on your behalf. Let’s say that your doctor has told you that you can’t lift anything over 15 pounds because of your injury, or you risk reinjury, but you work in a labor job that routinely requires you to carry over 30 pounds. The insurer may insist that there is other work you can do, but your employer may have no other role for you that doesn’t put you at risk. In this situation, a lawyer can talk to the insurer and employer for you, so the insurer can’t try to get you to admit that there is other work you can do. Your lawyer can submit hard evidence that you can’t return to your job.

Choosing the Right Disability Lawyer for Your Needs

Not all lawyers are the same. A lawyer who is highly skilled in contract law or divorce cases may not know how to best proceed when you get a denial letter after applying for disability benefits. When looking for the right disability lawyer, look for someone who has experience with disability claims. For example, at my law firm, Derek Wilson Injury and Disability Law, disability claims and personal injury are all we do. I have been in practice for over 30 years. It means I have helped countless people who are in your shoes right now — and I have secured compensation for them.

You’ll also want someone you can have a great working relationship with. You want someone who answers your questions, is honest with you, and replies to you. I have kept my law firm small on purpose so I can work individually on each case and give you the attention you deserve. It’s easy to reach me, and I always treat you with kindness and respect, acting in your best interests every step of the way.

Compensation Options

After you have been denied benefits, you will want to secure the money you should have received. There are a few options in most cases. One is to have your benefits reinstated. For example, your lawyer may reach an agreement with the insurance company where the insurer agrees to continue paying your benefits regularly and pay out any benefits you missed while your lawyer was working on the case.

Another option is to get a settlement. In a settlement, you get a sum of money that covers all the benefits you should have received and should receive in the future. It effectively makes the situation right and gives you the money you need. Once you have accepted a settlement, you can’t sue the insurance company further, and both you and the insurer will get to walk away from the situation. Your lawyer works to make sure you get a fair settlement that covers as much of your costs as possible.

Contact Us for a Free Consultation

Have you received a denial letter after applying for disability benefits? Contact me today for a free consultation so I can explain whether you might be able to get your rightful benefits after all.