Canada: Long-Term Disability Series: Received A Long-Term Disability Denial Letter? What To Do Next.

Last Updated: May 11 2017
Article by Brad Moscato

They say waiting is the hardest part.

But it is clear from my experience representing individuals who have been denied long-term disability that this is one of the toughest and most nerve-wracking times in a person's life.

At the moment you learn you've been denied, you may lose hope or fear what your life will look like if an illness, injury or medical condition is making it difficult or impossible for you to return to work.

But all hope is not lost when your insurer denies your long-term disability (LTD) claim. In this blog post, we review the steps you should consider taking when your claim is denied and why an initial rejection doesn't mean you will not recover benefits.

Seeking Long-Term Disability Benefits

When you are covered under a group insurance plan by your employer, and you are confronted by a medical condition that prevents you from working, you are likely first able to access short-term disability benefits. Hopefully, your condition improves and you are able to return to work and be in good health. But if you are not getting better, you will likely be referred to specialists for testing and assessments.

As you approach the end of your short-term disability benefits, and you apply for long-term disability benefits, the insurance company will begin the process of reviewing your medical records and reach a decision on your claim. Long-term disability claims may be  rejected for a number of reasons. These often include:

  • Insufficient information/documentation in the long-term disability application (or clerical errors);
  • Not meeting the eligibility requirements set out in the policy (for example, length of employment), policy exclusions (often related to a pre-existing condition), or based on disability definition (failure to meet a disability as currently defined by the medical community);
  • Treatment and assessment compliance (was the rehabilitation plan followed and did you complete the required assessments);
  • Surveillance (a private investigator may be hired by the insurance company to review your day-to-day activities – both physical living and online presence – to determine if there is evidence contrary to your application declarations).

Unfortunately, many legitimate claims are denied using the above reasons and others.

The Long-Term Disability Denial Letter

If you receive a letter denying your long-term disability benefits, but offering an opportunity to file an administrative appeal, your very first step should be to consult a lawyer with expertise in these types of cases. It is strongly recommended that you consult a lawyer as early on in the process as possible. You will have a limited period in which to appeal or commence a lawsuit.

Depending on the reasons the insurance company provided for you're denial, a lawyer may suggest considering a lawsuit immediately if there is justification, or using the appeal process. A qualified and experienced lawyer in long-term disability benefit denial cases can use their knowledge of the system (and often specific insurance companies) to begin the process of recovering your benefits and potentially more (i.e. bad faith or aggravated damage awards).

While the internal appeals process may be appropriate for certain cases, we often recommend otherwise, for a variety of reasons, including:

  • An insurance company may seek additional medical assessments to strengthen a denial decision that is in appeal but which they expect to end in litigation;
  • Time is not on your side. While an internal appeal works its way through the company, deadlines to begin litigation on some aspects of the case may pass, and the period you are without benefits or compensation increases;
  • The longer the process takes, the more likely you are to become emotionally or physically exhausted, financially strapped, and you simply move on without completing an appeal or litigation.

Make An Informed Decision

There may be legitimate reasons for an insurance company to deny long-term disability benefits. But if you believe your case deserves more consideration, whether through an internal appeal or lawsuit, it's always a good idea to have a lawyer with expertise in disability cases to review your file as soon as you've received word of your denial. An experienced lawyer can demystify the long-term disability claims experience, give you an idea of the strength of your initial application, and help you to decide the best way for you to move forward.

The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.

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