According to Statistics Canada, about 1 in 5 Canadians will suffer an injury at least once in their lifetime that impacts their daily functions*. Treating these injuries through our healthcare system cost Canadians billions of dollars every year**.
Life happens. You may not be as impervious to injury as you think. If you find yourself suffering from an injury or illness that’s had a significant impact on your ability to function, you should consider applying for long-term disability.
What is Long Term Disability?
Long term disability is a type of insurance. The insurance is intended to cover a portion of your monthly income if you are unable to work due to an illness or injury. You could have access to this insurance through your employer’s group benefits policy or through an individual policy that you pay the premiums for.
If an injury or an illness stops you from working, you should apply for long term disability benefits.
How Do I Apply?
Applying for long term disability is simple. There are three forms required:
- A form completed by you – Plan Member Statement,
- A form completed by your doctor – Attending Physician Statement, and
- A form completed by your employer – Plan Sponsor Statement.
You are responsible for providing your insurance company with forms 1 and 2 above. Your employer should deliver the Plan Sponsor Statement directly to your insurance company.
Once these forms have been submitted, the LTD case manager will decide on your claim.
How the Insurance Company Makes a Decision on Your LTD Benefits?
Your insurance company can either approve, deny or pend your claim.
If the insurer approves your claim, you will receive communication providing particulars of the approval, along with an explanation for when you can expect to receive payment.
If the insurer pends your claim, it could be for a few different reasons, including, but not limited to:
- The insurer is waiting for outstanding medical information,
- The insurer is scheduling an assessment and requires the assessor’s report before making a decision, or
- You could be awaiting a referral or assessment, and the insurer requires the results before making a decision.
Any of the aforementioned reasons could lead to the insurance company pending your claim.
Lastly, the insurer has the option of denying your claim. Below we discuss the most common reasons why an insurance company might deny your rightful entitlement to LTD benefits.
Top 10 Reasons Long Term Disability Claims are Denied
The insurer could deny your claim for several reasons. Sometimes a denial occurs outright after an application is submitted. Sometimes the denial occurs after the long-term disability benefit was approved.
Here’s a list of the most common reasons we’ve come across in helping people challenge the denial of their benefits:
- Insufficient Medical Information
If a medical record or report is missing or if your doctor did not send in the Attending Physician Statement, your insurer may deny your claim due to Insufficient Medical Information. You are responsible for providing medical documentation to the insurer. The insurance company can also request medical documentation, as this is within their discretion. It’s important to ensure all relevant medical information is provided to your insurance company so they have the full picture and can make an informed decision on your claim.
- Medical Evidence Does Not Support Total Disability
Information submitted or gathered on your medical condition is Medical Evidence. Per your long-term disability benefits policy, there is a definition of Total Disability. Your insurer is responsible for evaluating the Medical Evidence and determining whether your restrictions and limitations deem you Totally Disabled as per the policy wording.
- Medical Consultant has determined you are not Totally Disabled
The insurance company case manager assigned to your file has several “assessment tools”. These tools can be used to help your case manager understand your condition better. Assigning a Medical Consultant to review the medical documentation on an LTD claim is a commonly used assessment tool by the case managers. Be wary though, these Medical Consultants are contracted by the insurance company and will often support a finding that you are medically fit to return to work.
- Medical Assessment Report Has Determined You Are Not Totally Disabled
Another tool used by case managers is to schedule you for an Independent Medical Assessment. Like the Medical Consultants, these assessors are hired by the insurance company and will often support a finding that you are medically fit to return to work, despite your inability to do so.
- Change of Definition Denial
If your insurer has approved your claim, a Change of Definition occurs after two years. Initially when adjudicating your claim, the insurance company will evaluate whether the illness or injury prevents you from performing the essential duties of your own occupation. However, after two years, the definition changes and becomes broader. This is referred to as the Change of Definition period. After the two-year mark, the insurance company evaluates whether your illness or injury prevents you from performing the essential duties of any occupation that you are qualified for (or may become reasonably qualified). It is common for a denial of benefits to come after the Change of Definition.
- Denial Due to Workplace Issues
If your illness or injury is exaggerated by issues you are having in the workplace, your disability insurer may try to wedge your condition as resulting exclusively from the workplace. Issues with workplace harassment, belittling and bullying will have a negative impact on a person’s mental health. If you’ve submitted a disability application and workplace issues are present, your insurance company could deny your claim on the basis that it is work related and not related to your claimed injury or illness.
- Denied Due to a Pre-Existing Condition
Pre-existing condition denials will arise if you have been insured by a long-term disability policy for under a year. If you make a claim within the first year, the “pre-existing clause” will trigger, and the insurance company will investigate whether your claimed disability falls within the pre-existing period. Pre-existing denials are complicated, and it is important to seek an experienced lawyer’s help if your claim has been denied due to a pre-existing condition.
- Denied Due to Late Filed Application
Your disability policy will have timelines for when you should submit an application. It’s important to be aware of these timelines because if you file a late application, the insurance company can deny your claim for late filing. This means they will not consider the medical evidence you’ve submitted but deny you on a technical and contractual basis.
- Coverage Denial
A coverage denial is when the insurance company denies your claim for disability benefits because the insurer believes you did not have coverage when you submitted your claim. Coverage denials are complicated, you may believe you had coverage or were informed by your employer that you had coverage, when you did not.
- Denied Based on Surveillance
Insurance companies are notorious for conducting surveillance on disability applicants. If your insurer has conducted surveillance and utilized this surveillance to deny your benefits, you can ask for a copy of the surveillance. More importantly, you should consult a disability lawyer.
The above are common scenarios disability insurance companies use in denying benefits. If you’ve been denied for any reason, remember, you have rights and can challenge the wrongful denial of your disability claim. The disability team at Whitten & Lublin offer free consultations for short and long term disability denials. If your denial falls into one of the aforementioned reasons, contact us online or call 416 640 2667.
*Injuries in Canada: Insights from the Canadian Community Health Survey
**Quick facts on injury and poisoning – Canada.ca
Author – Aman Chaggar
