In 2019, there were 8,917 serious injuries caused by motor vehicle accidents in Canada. This number includes people admitted to hospitals for treatment and observation.
Serious injuries can significantly affect your life and those of your loved ones. Depending on the severity of your injuries, you may not be able to do your daily activities for a long time. The impact on your everyday life could include going back to work.
If you can’t work, you should be able to claim long-term disability benefits from the insurance provided by your employer or from a policy that you purchased on your own. Unfortunately, insurance companies often deny LTD claims unfairly. They give some reasons why they won’t provide the claimant with their disability benefits.
“I’ve worked both sides of personal injury law. I know how insurance companies think, and I’ve used this knowledge to help several clients obtain maximum LTD benefits even after they have gone through LTD denial.”
Derek Wilson
Reasons Insurance Carriers Give to Justify LTD Denials:
- You were late in filing your LTD claim
Check your insurance policy. Long-term disability policies usually come with a “Notice” clause or “Proof of Claim” clause. These clauses give a timeframe for submitting your claim for long-term disability benefits to the insurance company. The timeline begins to run from the date of your disability. If you are late in filing your claim, it can be denied by the insurer based on the clause in your policy.
Insurance companies often argue that if they receive a claim long after the claimant had the disability, their ability to manage the claim properly becomes biased. However, depending on the reasons for the delay and the extent of the delay, your LTD lawyer can successfully overturn decisions through legal arguments.
- You did not adhere to a contractual exclusion in your policy
This is one of the most common reasons for an LTD denial. It is based on a contractual exclusion – the “pre-existing condition exclusion clause.” This applies if you make a claim for disability benefits within the first year after your insurance coverage took effect (this is typically the one-year period after the policy’s effective date of coverage).
Suppose the insurer determines that you consulted a doctor or had any treatment related to your disability before your insurance took effect. In that case, they may deny your claim based on the pre-existing condition exclusion.
- You failed to have ongoing communication with your insurer
Just because you provided initial claim documentation to your insurer, this does not mean you don’t have to communicate with them after that. Insurance companies will continue communicating with you to get updated information and medical records to ensure that you continue to meet the tests for a disability specified under your long-term disability insurance policy. If they have attempted to communicate with you several times and don’t respond, they may deny or terminate your LTD benefits.
- You don’t have sufficient evidence to prove that you have a disability
It is not enough to provide your insurer with a diagnosis to establish that you have a disability. Insurance companies usually look for information about your symptoms’ severity, intensity, duration, and frequency. They also want to know how these affect your functional abilities. Your physician can provide this through a report highlighting the needed information that indicates that you are suffering from a debilitating medical condition.
- You refused to attend an independent medical evaluation (IME)
Insurance companies are generally allowed to have claimants assessed by a medical practitioner that they choose. They often have the right to send a claimant to a doctor for a medical or psychiatric evaluation under an insurance policy. The doctor will not provide treatment, but they will give an opinion to the insurance company on your symptoms, limitations if your condition is disabling, treatment recommendations, a diagnosis, and prognosis. If you refuse to attend an IME arranged by your insurer, this may lead to the termination or denial of your LTD benefits.
- The medical practitioner of the insurance company doesn’t think you are disabled
Unfortunately, agreeing to an IME is not a guarantee that the insurer’s medical practitioner will agree with your physician’s diagnosis. Often, the IME doctor hired by the insurance company will state that they don’t consider the claimant disabled. Of course, if you have complete medical records and the required report detailing your disability, this would be difficult for the insurer to dispute.
- You refused to comply with the treatment provided by your insurance company
Some LTD insurance policies require that the claimant submits to medical treatment if they want to receive benefits. If you must undergo medical treatment as stated in your insurance policy, and you refuse, your benefits may be denied or terminated.
- You failed to participate in a rehabilitation or return to work program
Even if the insurance company determines that you are qualified for long-term disability benefits, the claimant generally must make reasonable efforts to undergo rehabilitation. The purpose of the rehabilitation program is to eventually get you back to work, whether it is in your previous job or a new one. If, however, you cannot participate in a rehabilitation or return to work program for whatever reason, you have to consult with a long-term disability lawyer who will help you deal with the insurer regarding this matter. Otherwise, your benefits may be terminated.
- The insurance company does not find you credible
It is common practice for insurance companies to conduct surveillance because they believe it provides more accurate information of a claimant’s functional abilities when they are unaware that they are being watched. If the insurance company finds inconsistencies between what you are telling them and what they see on surveillance, your LTD claims may be terminated.
Testimonial
“I turned to Derek when my LTD claim was denied by the insurer. It was the best move I ever made. If you have never been involved in an LTD claim, it can be an overwhelming and drawn-out process. Derek was able to break it down in a way that I could understand. His knowledge and attention to the pertinent details are impeccable. Derek’s experience on both sides of the process works to level the playing field. In my case, this resulted in a positive outcome. The communication was exceptional. Both Derek and Taryn are direct, honest, compassionate, and, most of all, patient. Very easy to work with. Thank you. Highly recommended!”
M.B.
FAQs
If the insurance company denies my disability benefits, do I have to go to trial to receive them?
Most disability benefits denial cases do not go to trial. The majority of the lawsuits reach a successful settlement during mediation and negotiations.
My disability benefits have been denied. Who do I sue?
It is best to consult a lawyer. They will discuss your claim with you and determine which group or person you should sue. In most cases, the claimant sues the insurance company who is refusing to give the disability benefits. However, it depends on your situation. You may have to sue other parties, such as the insurance broker who sold you the policy.
If the insurance company agrees to settle, how will they pay me?
If you go to court with your disability benefits claim and win your case, they will award you with some or all of the disability benefits that you should have, and interest and costs, and all of these will be paid by the insurance company. It is also possible that the judge in charge of your case will order the insurance company to continue to pay for your benefits for as long as you are entitled to receive those benefits under your policy.
However, there have been cases where the insurance company agreed to the amount representing full and final payment to the claimant for past and future benefits. The agreed amount is determined between the claimant and the insurance company.
