Long-Term Disability Questions

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Your Questions, Answered

We know how difficult it is to apply for Long Term Disability (LTD). Filling out the required forms can be a daunting task.

And if your LTD has been denied or terminated, dealing with your insurance company can be stressful.

That’s why we have put together a list of frequently asked questions on LTD to help address some of your concerns.

If you are still unsure on what to do if your LTD has been denied or terminated, we would be happy to speak with you.

If your LTD has been denied or terminated, contact us for a free consultation. Call us at (905) 286-0050 or fill out our form on this page.

Frequently Asked Questions

What is long term disability insurance?

In the event of an injury or illness where you are not able to return to work, long term disability insurance offers some protection by providing you with a portion of your income that can go towards bills, expenses, and medical treatment and/or rehabilitation. Essentially, it aims to offset any financial hardship you might suffer as a result of being unable to return to work due to a medical condition.

Most policies provide benefits for the first two years if you are unable to meet the requirements for performing your own occupation, but after two years you must be unable to perform the tasks required by any occupation for which you are reasonably qualified by education, training or experience in order to retain long term disability benefits.

Watch this video to learn more about long term disability insurance in Ontario (View all LTD videos):

What is the difference between short term disability insurance and long term disability insurance?

Short term disability insurance can provide you with replacement wages in the event that you are temporarily unable to work. Long term disability insurance provides more permanent income replacement as your medical condition prevents you from working over a longer time period. Note that disability benefits are different from workplace insurance benefits as disability benefits arise from an illness or injury which is not required to occur on the job, whereas workplace compensation benefits are given as a result of being in the course of your employment.

What is the difference between individual disability insurance and group disability insurance?

Individual Disability Insurance is purchased by individuals privately in order to provide a safeguard against illness or injury which results in temporary and/or complete or total disability that prevents them from being able to work. You may choose to purchase additional disability insurance even if you already have some coverage from your employer. Insurance companies will usually offer a larger variety of features for individual disability insurance policies than they will for employer’s group disability insurance policies.

Group Disability Insurance is purchased by businesses and provides disability coverage to employees who are temporarily and/or completely or totally disabled and therefore unable to work as a result of a medical condition. If in a group plan, payments for the premiums may be paid by you through your paychecks or your employer may pay all or part of the premiums itself. Ask your employer if you are covered under such a policy.

What types of disability insurance are there?

Short Term Disability Insurance provides temporary income replacement if you are unable to work due to a medical condition (injury or illness). Usually this policy only covers income replacement for the first 120 days. Short term disability insurance benefits are usually purchased by employers for their employees

Long Term Disability Insurance offers a form of income protection in the event that an illness or disability leaves you totally or completely unable to return to work. It provides you with a portion of your income that can go towards living expenses which may also include medical treatment and rehabilitation. For the first two years if you are unable to meet the requirements of performing your own occupation then you are eligible. After two years you must be unable to perform the tasks required by any occupation for which you are reasonably qualified, or could become qualified for, by reason of education, training or experience, in order to retain long term disability benefits.

Critical Illness Insurance provides financial support in the event that a person is diagnosed with a ‘critical’ illness. Depending on the policy you purchase it may include cancer, stroke, heart disease, heart attack and usually 10-20 other serious medical conditions. These benefits will be paid regardless of the person’s ability to return to work. The benefit is paid in one lump sum; however, there is a ‘survival period’ for typically 30 days once diagnosed with the condition which must pass before that person can receive benefits.

Disability Mortgage Insurance provides you with financial support in the event that you become disabled and are unable to work. This policy covers all or part of your mortgage payment up to a certain amount bi-weekly or per month. There is typically a 60 day waiting period before you can receive benefits. There are also limitations in regards to duration and the amount of coverage that will be given.

Who pays for long term disability coverage?

Long term disability insurance can be purchased privately by individuals through an insurance broker or directly through an insurance company. Long term disability insurance can also be made available for purchase through your employer through a group disability insurance policy. In cases of group insurance through your employer, the insurance premiums could be paid by the employer, the employee or shared between the employer and the employee. Depending on what applies to you there are different implications for tax purposes.

If the employee pays the premiums for the long term disability insurance then disability payments are not taxable. If the employer pays for the disability insurance premiums then when the payments are made to the disabled employee they are taxable. The law is more complicated when the premiums are shared between an employee and employer.

What type of disability allows me to qualify for long term disability benefits?

Most long term disability policies cover you regardless of the severity or type of illness or injury you are suffering from that prevents you from working. However, some policies exclude certain illnesses, and others may exclude injuries or illnesses which are compensable under a Workplace Safety Insurance Board claim, if it is available through your workplace.

Generally, if you are not able to do all or substantially all of the tasks required by your current job then you will qualify for long term disability benefits. Essentially, the threshold is that your disability prevents you from being able to work. However, depending on your policy it may state that in order to qualify for disability benefits you must prove that it is not only your own job that you are unable to do, but any job that you may be qualified to do in consideration of your education, training or experience. Refer to your policy to see what applies to you.

Will I have to file a claim in order to receive long term disability benefits?

Yes, if you want to receive long term disability benefits it is required that you file a claim. Depending on where you are receiving your disability insurance consult your employer benefits booklet or your own private insurance policy. If you are receiving coverage from your employer contact your company for instructions on how to file your claim. Otherwise contact your insurance provider. Either way you will be required to fill out a claims form which will be provided to you by your employer or your insurance company.

What information is required on my disability claims form?

Information required when filing a disability claims form includes general demographic information, banking information, claim information, a list of health care professionals you have consulted, other income sources, occupational information, and diagnostic and treatment information regarding the physical and psychological aspects of your disability. Your claim will have different components to fill out for you, your employer, and physicians.

Specifically, for the claim information you will have to include the illness or injury you suffered (how, when and where), the symptoms, when you stopped working, when you received treatment by a physician, the duties of your occupation and why you are unable to perform them, etc.

While your own physician is likely required to fill out a form describing your condition and prognosis, the insurance company may ask you to be examined by one of their own doctors as well.

It’s very important that you accurately describe your symptoms to healthcare practitioners, so they can help you receive the care and compensation you need.

Watch this video about how to accurately describe pain to your doctor (View all LTD videos):

Are there deadlines when making a claim for long term disability insurance benefits?

Yes, there are deadlines or time limitations that are in place which can affect your ability to assert your claim. Therefore, don’t delay in contacting a disability insurance lawyer who will guide you through the process and notify you of any deadlines.

In order to receive disability benefits is it required that I be confined to a hospital?

No, hospital stays are not a factor in assessing the legitimacy of your disability claim as many medical conditions do not require long stays as treatment can be done at home or by professionals in other facilities.
What does it mean if my policy says that I must be “completely disabled” in order to qualify for benefits?
If in your policy it says that you must be “completely disabled” or have a “total disability” there may be a specified meaning according to your policy, usually in a definition section of the policy. Generally, it means that you are reasonably unable to carry out the normal functions of your usual job. It does not mean that you are physically unable to carry out the tasks of your job. Instead it means that in order to recover from your medical condition it is better for your health if you do not work.

Why does the insurance company require me to have an assessment done with a doctor they have chosen even though I have already gone to see my own doctor about my long term disability claim?

Within many long term disability policies there are provisions that require you to be assessed by a health care practitioner of their choosing in order to determine if you are entitled to benefits. When filling out your claim you are still required to go to your own doctor for an assessment.

While it is required that these insurance companies select health care practitioners that are reasonably qualified to undertake an assessment and the claimant’s exam must be reasonable, it is important to keep in mind that insurance companies make their money by collecting premiums not paying out claims. If you feel as though there has been unprofessional conduct by these assessment practitioners contact a qualified lawyer.

Is it legal for insurance companies to hire someone to follow and videotape me?

Yes, it is legal and normal for insurance companies to hire investigative companies to photograph and videotape claimants in order to assess the validity of their disability claim. The reason for this is that they want to ensure that there are no fraudulent claims or misrepresentations. Therefore, it is important that you be honest when filing your claim and speaking with doctors, specialists, your insurance company and your lawyer.However, if you feel as though investigative companies are putting you in danger, are trespassing, invading your privacy, or otherwise breaking the law you should contact the police.

How long do I have to wait to collect long term disability benefits?

Once you have made a claim how long you have to wait in order to collect your disability benefits depends on your policy as your claim must be evaluated, approved and a mandatory waiting period must be completed. If your employer has a Short Term Disability plan the waiting period to access the benefits under your plan is usually within 5 days.
For long term disability benefits, you will need to be off of work for several months before you can collect benefits. This waiting period is called an ‘elimination’ or ‘qualifying’ period and it can range from 90 to 180 days. Consult your policy and your employer for clarification.

There are alternatives if you do not have access to a short term disability plan. Instead you may qualify for Employment Insurance or Sickness Benefits through the Government of Canada. This can provide up to 15 weeks of sick benefits.

How much will I receive from long term disability insurance benefits?

For employer-sponsored group long term disability insurance, benefits can cover 50% to 80% of your pre-disability salary, with a typical policy covering 66.66%. However for many policies, there may be monthly maximums which put a limit on the amount you can receive.

For individual, private disability policies, benefits are pre-determined by the disability policy so that an injured or sick person already understands what their monthly disability benefit will amount to in the event they are unable to work.

How long do the long term disability insurance benefits last?

The duration of your long term disability insurance plan depends on the policy you have purchased. Some have a set time frame such as 5 or 10 years, while others can last until you are 65 years old. There are policies that also have a lifetime benefit which usually pays a percentage of what you were receiving up to age 65 and then a lesser amount for the next 5, 10, 15 years or even for life.

Are my benefits taxable?

Generally, if you, the employee, have an individual disability insurance policy where you pay the premiums then any payments you receive are not taxable. If the employer pays the premiums for the employee’s disability insurance policy then when the benefit payments are received by the disabled employee they are taxable.

Can other benefits be deducted from my long term disability payment?

Yes, most long term disability policies typically have provisions which reduce the monthly payment you receive by accounting for:

  • Benefits payable from any Workers’ Compensation plan, including Workplace Safety Insurance payments
  • Disability benefits received under any other government program such as, Canadian Pension Plan- Disability, Ontario Disability Support Program, Employment Insurance- Sickness Benefits, etc.
  • Income from the Criminal Injuries Compensation Act
  • Wages or remuneration payable from, any employer, including any statutory or common law termination and/or severance pay

Consult your policy for specifics as your long term disability benefit may also be reduced by monies payable to your dependents (i.e. minor children) for the aforementioned areas.

Can my long term disability insurance company force me to apply for Canadian Pension Plan (CPP) Disability or other benefits?

Many policies contain provisions that allow the insurance company the power to make you apply for benefits from another source. If you apply and are denied benefits you may be required to appeal the decision. Consult your insurance policy or speak to an insurance representative to see what applies to you and your policy.

What policy ‘riders’ can you purchase with long term disability policies?

A policy rider or endorsement provides extra coverage to your already existing long term disability policy. These riders are usually only offered with private disability policies and if not purchased at the time of the original application, will require that a medical form be completed before the rider can be added into the policy.

a) Cost of Living Adjustment
This rider policy considers your salary and inflation yearly and adjusts your benefits accordingly.

b) Own Occupation to 65
Professionals or people with specialized skills may find this rider policy beneficial as it eliminates the ‘Any Occupation Test’ and provides the disabled individual with long term disability benefits as long as he/she is unable to perform the essential duties of their own occupation or until age 65, whichever is sooner.

c) Future Earnings Protection Option
When you initially apply for your long term disability policy you are required to provide your current salary as this is needed to determine what your long term disability payment would be in the event of an illness or injury that prevents you from returning to work. Most often when you have a wage increase your policy should be readjusted to reflect this change. However, wage increases result in a larger disability payment which triggers a new policy application which then triggers a new medical. A future earnings protection option allows you to avoid providing a new medical. This can be invaluable in the event your health has deteriorated since your last application for disability benefits was submitted.

Does long term disability provide extended medical or dental care as well?

No, long term disability policies are designed to only provide wage replacement. However, if you have a benefit plan with your employer and are unable to return to work because of a long term disability then you may be able to get a benefit continuation paid by your employer while you are on long term disability.

I am on long term disability, and my employer terminated my employment. What does this mean for my long term disability entitlement?

As long as you were actively employed at the time you became disabled then your termination of employment should not affect your long term disability entitlement. However, any termination and/or severance payments may be deducted from your long term disability entitlement. The situation may be more difficult if you were on short term disability at the time you were terminated or were on temporary layoff when you became disabled.

After being unable to work at my own job for two years can my insurance company stop paying me my benefits?

For most policies you are entitled to claim long term disability benefits for the first 2 years of being unable to perform the essential duties of your own job. This is called the “Own Occupation Test.” After this 2 year time period your eligibility for long term disability benefits will likely change. It will then be based on whether you are unable to perform any occupation for which you are reasonably qualified, or could become qualified for, by taking into consideration education, training or experience. This is called the “Any Occupation Test”.

Why has my long term disability claim been denied? Why have my long term disability benefits been terminated?

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):

I just received a letter from my insurance company terminating my benefits. What should I do?

It is important that you try to find out why your benefits have been terminated. Carefully reading over the letter that your insurance company sent you may provide this information. For example, if your benefits were terminated because you did not send the insurance company the proper documentation contact your insurance provider and arrange for the necessary forms and documentation to be sent to them as soon as possible.

However, if the reason for your termination is that the insurance company no longer finds that you are disabled enough as to require benefits even though your doctor maintains that you are still disabled, contact a disability insurance lawyer.

I was recently denied long term disability benefits, when should I get a lawyer involved?

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.

Do I need a lawyer to handle my long term disability insurance claim?

It is a personal choice in deciding whether or not you would like a disability insurance lawyer to represent you and handle your claim. It is important to be aware of your rights and stay in control of your situation. When a person negotiates directly with an insurance company, he or she needs to understand that insurance companies have hundreds of years of experience in how to manage and settle losses. As private companies, they are always working for the benefit of its shareholders. If your claim is denied you may wish to consult with a lawyer who has the experience and knowledge necessary for advancing your claim.

How much will it cost to sue my insurance company?

Roger Foisy, as do most disability insurance lawyers, works on a contingency fee basis. This means that the lawyer only collects their legal fee if they are successful in your claim. In addition, Roger R. Foisy Professional Corporation offers an initial free consultation to potential clients. For a helpful explanation on how fees are determined please see my video blog How Ontario Injury Lawyer Fees are Determined.

What can I do to maximize my chances of success in filing a disability insurance claim?

When filing a disability claim it is important that you go to a doctor or a specialist who has an expertise in the medical condition that you are coping with. This way they have the ability to more accurately detail your prognosis and required treatment. It is also important that you discuss with them your job duties and responsibilities and how your condition may affect your ability to do these tasks. Consider the physical and mental demands that are required and what limitations you will face. This is important when evaluating whether you can fulfill the essentials of your own job as determined in the ‘Own Occupation test’.

I think that I need to sue for disability benefits, but I have no income. What if I cannot afford a lawyer?

Most disability insurance lawyers, including Roger Foisy, work on a contingency fee basis. This means that the lawyer only collects their legal fee if they are successful in your claim. In addition, Roger R. Foisy Professional Corporation offers an initial free consultation to potential clients. For a helpful explanation on how fees are determined please see my video blog How Ontario Injury Lawyer Fees are Determined.

Who do I sue if my disability benefits are denied?

Your lawyer will discuss your claim with you and determine which person or group it is appropriate for you to sue. Most of the time you will be suing the insurance company who is refusing to give you disability benefits. However, depending on your situation it may be necessary to sue other parties, such as, the broker who sold you the policy. Your lawyer will work with you to decide the best course of action.

When I sue the insurance company for disability benefits what do I actually sue for?

In long term disability actions you are suing for the payment of the disability benefits to which you are entitled. If you and your lawyer decide that the insurance company acted unfairly when they denied your claim you may also sue for ‘bad faith’. Your lawyer will also make a claim for pre- and post-judgment interest on the amounts claimed along with a financial contribution from the defendants which will go towards your legal fees.

What is the process for suing the insurance company?

After discussing the nature of your claim with your lawyer and agreeing that suing is the best way to proceed, your lawyer will deliver a Statement of Claim which sets out the allegations you are making against the insurance company. The insurance company in response will file a Defence and then documents from both parties will be exchanged. During this process, you will be asked questions under oath and will likely have to undergo medical assessments both with your own doctor or a specialist and a doctor chosen by the insurance company. You will have to take part in settlement negotiations and potentially mediation will occur. Going to trial will be the final step, which is usually unnecessary as the majority of all lawsuits settle beforehand.

If I have been denied disability benefits do I have to go to court to receive them?

Most disability benefits claims do not end up going to trial. In the process of suing for disability benefits the majority of lawsuits reach a successful settlement during the process of negotiations and mediation.

If the insurance company agrees that I am still entitled to benefits, what are the different ways that my settlement can be paid to me?

If your disability benefits claim goes to court and is successful then you will be awarded some or all of the outstanding disability benefits that you should have, plus interest and costs, all of which is paid by the insurance company. The judge hearing your case may also order that the insurance company continue to pay for your benefits into the future as long as you are entitled to receive such benefits under your policy.

However, many cases settle on the basis of an agreed amount of money that represents a full and final payment to you for past and future benefits. This agreed amount is determined between you (the claimant) and the insurance company.

If your LTD has been denied or terminated, contact us for a free consultation. Call us at (905) 286-0050 or fill out our form on this page.

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