Frequently Asked Questions About Long-Term Disability

An insurance company may deny your Long-term disability claim or terminate your Long-term disability benefits for a variety of reasons. Some of these might have a simple solution, such as making sure that they have all the necessary forms and documentation, but in other cases it might require the assistance of a lawyer to help you in your claim against the insurer in order to get the benefits that you are entitled to.

Issues may arise if you are not examined by insurance company approved doctors, you exceeded the time limitation in submitting a claim, there was a misrepresentation on the application as you had a pre-existing condition that you did not mention, there is surveillance evidence that contradicts your claim, there was a failure to have your injury or condition properly documented by your physician, you have not ‘mitigated your losses’ by maintaining your treatment regimen, or there was a failure of your employer to provide the necessary documentation.

Another common reason for a denial of benefits is that after two years of receiving Long-term disability benefits many policies state that you must not be able to perform the duties of any occupation you are reasonably qualified or could become qualified for (Any Occupation test) in order to continue receiving benefits. This is different from when you first receive Long-term disability benefits as then you need only be unable to perform the essential duties of your own current occupation before you became disabled (Own Occupation test). You will always require a medical opinion to be able to prove that you meet these disability requirements.

Similarly, insurance companies may argue that you do not have a claim or that you are partially or residually disabled (meaning you do not have access to Long-term disability benefits as you do not suffer a total disability which prevents you from working). Instead, you are able to work part-time or with modified tasks. It may also consider your loss of earnings as a result of the medical condition. However, the benefits you would receive would be less than if you were receiving Long-term disability benefits.

Watch these videos explaining the top 10 reasons why an insurance company might deny your Long-term disability claim (View all LTD videos):

With more than 20 years of representing clients with long-term disability cases, I have witnessed less than a handful of successful appeals and those successes have been the usual result of administrative errors such as employer mistakes in forma completion. Appeals take away valuable time away from a lawyer’s ability to start advocating on your behalf.

As previously discussed, unless there is an obvious clerical error noted in either of your LTD application; the employer’s statement; or, the physician’s statement, that restores a 100% certainty regarding your disability, the insurance company will rubber stamp its original decision. Disability insurance companies remain focussed on profits for its shareholders. Our experience is that they find any reason, no matter how weak to deny your claim. Appeals are just another process to delay payment of another valid LTD benefit claim.

NO, neither the law nor the disability policy requires an LTD disability applicant who has been denied or terminated from appealing the insurance company’s decision. However, it is important to recognize that LTD disability appeals are different from disability limitation periods

An Appeal period is the amount of time given by your disability insurance company following its decision to deny or terminate your LTD benefits.  As previously mentioned, despite your insurer’s request to appeal its decision, neither the law nor the disability policy requires you to appeal.

A Limitation period is a strict amount of time you have commence a law suit as against your insurance company for the denial or termination of your disability benefits. Please be advised that there are strict limitations periods in contractual agreements between parties which the limitation period could be one year or more.  If there is no mention of a limitation period, the Ontario Limitations Act, 2002, provides the limitation period.

Pursuant to the Ontario Limitations Act, 2002, “a proceeding shall not be commenced in respect of a claim after the second anniversary of the day on which the claim was discovered.”

The Limitations Act provides that a claim is discovered on the earlier of,

1. the day on which the person with the claim first knew,
   • that the injury, loss or damage had occurred,
   • that the injury, loss or damage was caused by or contributed to by an act or omission,
   • that the act or omission was that of the person against whom the claim is made, and
   • that, having regard to the nature of the injury, loss or damage, a proceeding would be an appropriate means to seek to remedy it; and
2. the day on which a reasonable person with the abilities and in the circumstances of the person with the claim first ought to have known of the matters referred to in clause (a).

The courts have held that the question of when a claim is “discovered” is a question of fact; however, a disability claim is essentially discovered when the disability claim has been clearly and unequivocally denied.

In other words, a disability claim is discovered when:

1. a claimant believes or a claimant is told by his or her health care practitioner(s), that  he or she is disabled, and,
2. the claimant has disability insurance coverage, and,
3. those disability insurance benefits have
   • never been paid to them; or,
   • the amount of disability benefits being paid is incorrect; or,
   • the disability benefits once paid to the claimant are no longer being paid.

It is important to seek the advice of a disability lawyer as soon as your LTD benefits are denied or terminated

Due to deadlines for filing a claim against your disability insurance provider it is important that you seek out a qualified lawyer and as soon as your disability claim is denied.