What to do if You are Denied Long-Term Disability Benefits

When faced with a circumstance that changes your life, like a disabling accident, there is a way to collect benefits if you are unable to work. Long-term Disability (LTD) benefits are often part of an employer’s private insurance plan but may also be purchased through individual insurance plans.

Long-term disability benefits play an important role in providing you with financial support if you cannot work because of a permanent injury or an illness. However, it is common for insurance companies to deny legitimate long-term disability claims. A denial can leave you confused, shocked, and afraid as you wonder how you will support yourself and your loved ones since you can no longer engage in meaningful employment or other profitable activity.

Many long-term disability insurance companies in Ontario are always looking for reasons to deny insurance claims. By failing to provide you with benefits, the companies increase their profits. However, you should not lose hope after having your application for long-term disability denied in Ontario. You only need to consult an experienced long-term disability lawyer Toronto to help you review your legal options. Insurance companies do not have your interests at heart, but your lawyer does.

Why Long-Term Disability Claims Are Denied in Ontario

When you suffer an illness or injury that prevents you from working, long-term disability benefits can give you the financial support you need. However, most applicants are denied LTD benefits. When insurance coverage is denied, people do not challenge the insurance company’s decision mainly because they feel intimidated by the insurance company. It is a tough battle between applicants with no experience in filing disability claims and multi-billion dollar insurance companies that understand everything about disability claims.

The common reasons for long-term disability claims denial include the following:

Inadequate Medical Evidence/Documentation

Most insurers deny long-term disability claims by alleging that applicants have not provided enough medical documentation to prove the said disability. The denial letter comes with many details and explanations. In most cases, the insurer’s interpretation of the facts outlined in the medical documentation is never in line with the applicant’s interpretation of them. Most claimants give up because of fear. The intricate denial letter issued to the claimant is an intimidation tactic aimed at discouraging the applicant from moving forward. When you contact a lawyer, the lawyer will probably work with the documentation you had initially submitted since the documentation was just fine, to begin with.

Insurers May Claim That You Haven’t Suffered Long-term Disability

Long-term disability means that an illness or injury prevents you from performing the essential duties of your occupation or any other occupation for which you are suited by education, training, or experience. However, insurance companies will want to make you think that a long-term disability is a catastrophic injury or illness, yet this is not the case. The insurance company can claim that its consultant or medical doctor doesn’t think that you are disabled.

Many insurance policies claim that after receiving disability benefits for two years, it must be evident that you can’t perform duties of any occupation that you are qualified for or you could become qualified for to continue receiving the benefits. These requirements differ from the requirements when applying for disability benefits the first time. During the first application, you only need to prove that your disability makes you unable to perform the duties of the occupation you had before you suffered the disability.

The insurer is likely to deny your claim if you are partially or residually disabled. If you can work part-time or on modified tasks, you will not be eligible for compensation. However, even with a partial disability, you can still access disability benefits, only that the benefits will be less than what you would receive for a long-term disability.

Other reasons that could lead to a disability claim denial include:

• If you have not been examined by an insurance-company-approved doctor.
• You have exceeded the allowable time limit for submitting the claim.
• There was a misrepresentation in your disability benefits application, including failing to mention pre-existing medical conditions.
• If the insurance company has surveillance evidence that contradicts your disability claim.
• Your doctor did not document your injury or medical condition properly.
• Your employer did not provide the necessary documentation.

What to Do When You Are Denied for Long-Term Disability

What should you do after having your long-term disability denied in Ontario? You should not lose hope even if the insurance company identifies more than one reason for denying your disability claim. You have a right to question the denial to understand the reasons why the insurer denied the claim. An experienced lawyer can help you challenge the insurer’s decision. A lawyer understands the right questions to ask and will determine if the insurance company has legitimate reasons for denying your claim.

Here’s what you should do when the insurance company denies your claim:

Request for the Denial Letter In Writing

When your insurer denies your disability claim, you should get the decision in writing. The denial letter from your insurer will outline the reasons for your long-term disability claim denial. The letter will also state the limitation period within which you should submit your claim – usually, this period is two years. The letter will also give guidelines on how to appeal the insurer’s decision.

In most cases, your insurer will call you and explain over the phone why your claim was denied. Before you end the call, you should insist on the denial letter in writing. When you obtain the letter, gather other documents that are relevant to the claim, including the policy documents, and give them to your disability lawyer. Your lawyer will review your case, identify any lapses or mistakes the insurance company could have made when handling your claim and help you secure the rightful compensation.

Obtain Supporting Documentation

Sometimes, the insurer may deny your claim on the basis of inadequate documentation or supporting medical information. You should qualify for long-term disability benefits if your doctor says you cannot work because of your injury or illness. When filing a disability claim, your insurer will require a well-filled physician statement. You should have this form double-checked to ensure that it is well-filled before you file an appeal.

Perhaps you did not fill out the application form properly, and the insurance company used this as a basis for denying your application. You can seek help in filling out the application to avoid errors or omissions that could make the appeal unsuccessful.

File A Legal Claim Instead of Appealing

In most cases, appeals for disability benefits do not work after the initial LTD claim denial. It is better to file a legal claim against the insurance company. When you appeal, the same insurance company that denied you the benefits in the first place will still handle the appeal. Most insurance companies use the appeal process to stall out the two-year window for filing the claim. In this case, you will not have time to file a legal claim to seek compensation. The insurance company doesn’t have to pay your long-term disability claim once the two years are over. Since the limitation period will be over, you can’t file an appeal.

When you submit a claim for disability benefits, the insurance company can choose to award the benefits or spend money fighting a lawsuit. When applicants file claims against insurance companies, most insurance companies choose to pay the disability benefits instead of hiring a defence lawyer because lawyers are more expensive.

If your insurer has denied you disability benefits, you should let a lawyer fight for you. You should contact a lawyer immediately if you see some red signs in the way the insurance company is handling your claim. When you contact a lawyer early, you will give them ample time to prepare your claim before the expiry of the limitation period. Lawyers understand the tricks that insurance companies use to deny deserving applicants disability benefits. A lawyer will hold the insurance company for the claim that is denied unfairly.

At Grillo Law, we regularly handle disability claim denials in Ontario and across Canada. For years, we have helped numerous clients secure disability benefits. Our lawyers give applicants the advice they need and help them secure the compensation they deserve.

FAQs – Denied LTD Benefits

1. What Should I Do to Maximize My Chances of Success when Filing a Disability Claim?

When filing a long-term disability claim, you should contact a physician or specialist with expertise in the medical condition or injury you are dealing with. By doing this, you can be sure that the doctor will give you the right prognosis and the necessary treatment. You should also discuss your job roles and responsibilities with the doctor to determine how your medical condition will affect your ability to perform these duties. What limitations will you face because of your injury or medical condition? This evaluation will be essential when determining if you can perform the requirements of your job as outlined in the “Own Occupation Test.”

2. Why Did My Insurer Deny My LTD Application?

Your insurer can deny your LTD application or even terminate your long-term disability benefits for several reasons. Some reasons are easy to resolve, like when you only need to provide the necessary forms and documentation. However, some reasons are beyond you, and you will need to consult a lawyer to help you file a lawsuit against the insurance company to help you secure the compensation you deserve. A common reason for disability benefits denial is if you did not undergo evaluation by an approved doctor, if there was a misrepresentation of facts in the application, or if you did not submit your application within the time limitation. The insurer could also deny your claim if the insurance company has surveillance evidence that doesn’t match the facts outlined in your application if the physician did not document your injury or illness accordingly, or if your employer did not avail the necessary documentation.

3. Does It Make Sense to Appeal a Disability Claim?

There is no use in filing an appeal when an insurer denies your disability claim. The same insurance company that denied your claim is still the one to handle the appeal, meaning that it is likely to rubber-stamp its initial decision. However, it makes sense to appeal a disability claim denial if the denial was due to an obvious clerical error in your application, the physician’s statement, or the employer’s statement. In this case, you are certain that your appeal will be successful. However, if the denial was not due to a clerical error, the insurance company will likely find another reason to deny your claim. Insurance companies use appeals as a way of delaying disability claims so that the limitation period expires.

4. What is the Typical Success Rate of Appeals?

The success rate of appeals is quite low. Many disability lawyers point out that in over 20 years of representing clients filing long-term disability claims, they only witnessed a handful of successful appeals, and these appeals are usually for cases denied due to administrative errors, including errors when filling out the application form. An appeal only causes delay and uses up the time that a lawyer would use to prepare a legal claim for your benefits.

5. What is a Disability Benefit Limitation Period?

A limitation period is the time you have to file a lawsuit against the insurance company following a denial of your disability benefits. According to Ontario Limitations Act, 2002, you can’t commence a proceeding with respect to a disability claim after the second anniversary from the time you discovered the claim. The Limitations Act defines the day when the claim was discovered as:-

• When you first know about the injury, damage, or loss that had occurred
• When you knew that the injury, damage, or loss was due to an act or omission
• The act or the omission is against the person against whom you make the claim
• Given the nature of the injury, damage, or loss, a proceeding would be a proper way of seeking its remedy

It is crucial to consult a lawyer immediately when your claim is denied to commence the legal process.

6. Should I Hire a Lawyer To Handle My Long-term Disability Insurance Claim?

You have the freedom to choose whether to hire a lawyer to represent you when filing a disability claim or to go it alone. The law doesn’t require you to hire a disability lawyer when filing a disability claim. However, a lawyer helps you understand your rights and stay in control of the process to ensure that the insurer doesn’t take advantage of you. Before you choose to face the insurance company on your own, you should understand that the insurance company has years of experience in handling disability claims. The insurance company doesn’t have your interests at heart but works for the well-being of its shareholders. Working with a lawyer increases your chances of approval. If the insurance company denies your claim, you should contact a lawyer to help you bring a lawsuit against the insurance company.

7. Who Do I Sue When My Disability Benefits Are Denied?

After a denial of your long-term disability benefits application, your lawyer will advise you about the party you should sue. In most cases, claimants sue insurance companies for refusing to award them disability benefits. However, it might be necessary to sue other parties alongside the insurance company, but this will depend on your situation. For example, you can choose to sue the broker who marketed and sold you the insurance policy. Your lawyer will evaluate your case and advise you on the best course of action. You may file a lawsuit against the insurance for acting in bad faith if you and your lawyer believe that the insurer acted unfairly when denying your claim.

8. What is the Process of Suing the Insurance Company?

The first step involves discussing the case with your lawyer to determine whether suing the insurance company is the best course of action. If you decide to sue, your lawyer will provide a Statement of Claim outlining the accusations you are making against the insurance company. The insurance company will file a defence in response. Both you and your lawyer and the insurance company and its defence lawyer will exchange the necessary documents. During this process, you will likely undergo a medical assessment with your specialist or a doctor chosen by the insurance company. You may also be required to answer some questions under oath. Together with your lawyer, you will take part in a settlement process where mediation may occur. If you cannot settle the case out of court, the case will proceed to trial to have the judge or jury make a ruling.

9. I Have Filed an Appeal; What Should I Do?

Perhaps you have filed an appeal to have the insurance company pay your disability benefits, but the insurer still turned down your request. What should you do now? You still have options even if your appeal is not successful. Provided two years have not passed since the denial of your disability benefits application, you can consult an experienced lawyer to review your situation and help you seek the compensation you deserve. When you hire a lawyer, the lawyer will handle all the communications with the insurance company while you concentrate on your health and recovery.

10. What If I Can’t Afford a Disability Lawyer?

Perhaps you think that you should file a lawsuit for disability benefits, but you have no income and can’t afford a disability lawyer. The good news is that most disability lawyers work on a contingency basis. This means that you will only pay the lawyer if they are successful in securing disability benefits for you. Most lawyers also offer a free initial consultation to prospective clients.

How Grillo Lawyer Can Help You with Long-Term Disability Denied

If your insurer has denied your long-term disability claim in Ontario or you have been cut off from receiving your disability benefits, our lawyers at Grillo Law can help. We have been handling disability benefit claims for years. We understand everything about disability benefits and claims. Some of our lawyers have worked for insurance companies before, meaning that they understand how insurance companies operate, why they make certain verdicts, and how you can fight for your rights. We have helped thousands of clients in Ontario to secure long-term disability benefits. It does not matter whether your disability claim has been denied or your disability benefits have been cut off prematurely; we can hold the insurance company accountable.

Our disability lawyers in Ontario provide free consultations. We work on a contingency basis, meaning that you will only pay us when we secure you the compensation you deserve.