You know you can’t work, your family agrees and your doctor has confirmed that you are medically unable to work. Is your long-term disability (“LTD”) provider the only one saying the opposite? It may seem obvious that your long-term disability (LTD) claim should be approved. Unfortunately, many Canadians discover this is not always the case. Even with medical support and documentation, disability insurance companies sometimes deny legitimate claims.
Understanding why this happens is critical if your benefits have been refused. Insurance companies assess claims according to strict policy definitions and often scrutinize medical records for evidence of functional limitations, not just diagnoses. Consequently, claims may be denied even when a physician clearly states that the claimant cannot work.
This guide explains why LTD claims can still be denied despite doctors’ support, what evidence insurers look for, and what steps you can take if your disability benefits have been refused.
Can your long-term disability claim be denied even if your doctor says you can’t work?
Yes. Long-term disability insurers do not automatically approve claims based solely on a doctor’s opinion. Insurance companies evaluate whether the medical evidence proves that you meet the disability definition in your insurance policy. If medical records lack detailed functional limitations or if the insurer interprets the evidence differently, a claim can still be denied. In these cases, claimants may challenge the denial with additional medical evidence or legal assistance.
What happens to your LTD claim when your doctor confirms you can’t work?
When applying for long term disability benefits, you will need the support of your doctor. Your doctor is required to fill out a form as part of your LTD application called the Attending Physician Statement.
This form provides details of:
- Your diagnosis
- Symptoms related to your condition
- Accompanying restrictions and limitations
- Whether you can perform the duties of your job based on restrictions and limitation
- Expected recovery time
Generally, having your doctor’s support means your LTD claim should be approved, but that is often not the case. Insurance companies assess whether the medical evidence supports the definition of disability outlined in your policy, instead of taking your doctor’s diagnosis and opinion at face value.
Requirements to receive LTD benefits
Detailed medical notes are critical when applying for LTD. If your clinical notes contain a diagnosis but do not expand on the functional or mental limitations stemming from that diagnosis, it will be harder for the LTD insurer to approve your claim.
Insurance companies are looking for medical evidence showing how your condition prevents you from working, not just confirmation of a diagnosis.
You can help support your claim by providing your insurance company with the following information:
- Your symptoms and how they affect our daily life
- What medications are you taking
- What are the side effects do they cause
- How your condition affects your ability to complete daily routine activities?
Providing answers to these questions can give your insurance company a better picture of your struggles and how your condition has impacted your ability to work.
What medical evidence does insurance companies look for in LTD claims?
When assessing a long-term disability claim, insurance companies look beyond a diagnosis. Their main focus is whether the medical evidence clearly demonstrates that your condition prevents you from performing the duties of your job.
Key types of medical evidence insurers often review include:
- Clinical notes from your family doctor
- Specialist reports from psychiatrists, neurologists, orthopaedic surgeons, or other treating physicians
- Diagnostic test results, such as MRIs, blood tests, or imaging
- Medication records, including side effects that may affect your ability to function
- Functional assessments describing physical or cognitive limitations
- Treatment history, including therapy, rehabilitation, or specialist referrals
Detailed documentation explaining how symptoms affect your daily functioning and work capacity can significantly strengthen your claim.
Why LTD claims are sometimes denied despite doctor’s support?
Even when your doctor supports your LTD claim, insurers are notorious for denying claims they should be paying for several reasons:
- The insurer applies the policy definition of disability
Insurance companies evaluate your claim based on whether you meet the test within your LTD policy. Most LTD policies define disability differently during different stages of a claim. Initially, you may need to prove you cannot perform your own occupation, and later that you cannot perform any occupation.
- Insurers focus on functional limitations
A diagnosis alone is usually not enough. Insurers want evidence showing how the condition limits your ability to perform work duties.
- Case managers interpret medical records
LTD claims are evaluated by insurance company case managers. They review the medical documentation and decide if it satisfies the policy requirements.
Since your claim is being adjudicated by a case manager who works for the insurer, you may be at the mercy of the case manager’s interpretation of information you submit.
In some cases, insurers may:
- Focus on selective portions of medical records
- Request additional medical reviews
- Downplay the severity of symptoms
- Interpret medical evidence differently than your doctor
The odds are stacked against you from the start and insurers often cherry pick or twist your medical information to deny your claim. This is one reason why many legitimate claims are denied.
Signs your long-term disability claim may be wrongfully denied
Many people are surprised when their LTD benefits are denied, especially if their doctor supports their inability to work. In some situations, the denial may be questionable.
Possible warning signs of a wrongful denial include:
- The insurer ignores or dismisses your doctor’s opinion
- The denial letter focuses on minor inconsistencies in medical notes
- The insurer relies on a brief file review by a doctor who has never examined you
- The insurer claims there is “insufficient objective evidence” despite ongoing treatment
- Your condition is minimized or mischaracterized in the denial explanation
If you notice these issues, it may be helpful to seek legal advice from a disability lawyer to determine whether the insurer has acted unfairly.
What to do if your LTD claim is denied?
If your LTD claim has been wrongfully denied, it does not necessarily mean the insurer’s decision is final.
Possible next steps include:
- Reviewing the denial letter carefully
- Gathering additional medical evidence
- Consulting a disability lawyer about your legal options
Having legal representation means you can challenge the LTD denial in court.
How to strengthen your long-term disability claim?
If you are applying for LTD benefits or preparing to challenge a denial, there are several steps you can take to strengthen your claim.
Helpful strategies include:
- Keep consistent medical appointments
Regular visits with your doctor create a documented record of your symptoms and limitations. - Ask your doctor to document functional restrictions
Medical records should explain how your condition affects your ability to sit, stand, concentrate, lift, or perform job duties. - Follow recommended treatment plans
Insurers often expect claimants to pursue reasonable treatment options. - Track your symptoms and daily limitations
Keeping a disability journal can help demonstrate how your condition affects your daily life. - Consult a disability lawyer early if problems arise
Legal guidance can help ensure your evidence is properly presented and interpreted.
Frequently asked questions
Can an insurance company deny LTD if my doctor says I can’t work?
Yes. Insurance companies are not required to accept a doctor’s opinion alone. They evaluate whether the medical evidence proves you meet the disability definition in your policy.
What evidence strengthens a long term disability claim?
Strong LTD claims typically include detailed medical records, clinical notes, diagnostic testing, specialist reports, and documentation explaining how symptoms prevent you from performing work duties.
Why do insurance companies deny legitimate disability claims?
Insurers may deny claims if they believe the medical evidence does not prove functional limitations, if documentation is incomplete, or if their interpretation of the evidence differs from the treating physician.
Should I appeal an LTD denial or speak with a disability lawyer?
If your claim has been denied, speaking with a disability lawyer can help you understand whether the denial was justified and what legal options may be available to recover your benefits.
Quick Summary: Doctor Supports Disability but LTD Denied
If your doctor confirms you cannot work but your long-term disability claim is denied, the insurer may believe the medical evidence does not satisfy the disability definition in your policy. Insurance companies often focus on documented functional limitations rather than the diagnosis alone. If your claim has been denied, additional medical evidence or legal guidance may help challenge the decision.
Why contact a disability lawyer?
A disability lawyer can even the playing field by advocating for you and clarify the medical information the insurer has intentionally misconstrued.
The disability legal team at Whitten and Lublin offers free consultations for short and long-term disability denials. Contact us online or call 416 640 2667.
Author – Aman Chaggar
