Long-Term Disability Denied? Here’s What You Need To Know

If you’re facing a serious illness in Ontario, whether that illness is mental, physical, or some combination thereof, your health is likely making it difficult or even impossible to work. Aside from trying to manage symptoms enough to simply get through the day, there’s often associated depression and anxiety from worrying about your prognosis, treatment, and when things might improve. 

When you can no longer work, your doctor may support you applying for short-term or long-term disability. While short-term disability benefits are meant to run for a number of weeks, long-term disability benefits (or “LTD”) can run for months, or even years depending on the nature of your illness. The application is a complicated process and requires extensive paperwork along with medical documentation.

So what happens when your insurance provider denies your claim? What options do you have when your LTD application is denied?

Believe it or not, a denial is NOT the end of the road, and there are other options to explore.

Why are LTD claims denied?

There are various reasons that insurance providers use to deny LTD claims, and they are not all fair, and sometimes may not even be valid. Sometimes reasons are medical, such as claiming that you have insufficient medical documentation. Even if you have letters from multiple doctors and specialists, providers can still make this claim. Remember, the insurance provider is not the expert in your condition – your doctor is.

In other cases, the insurance provider may try to send you to someone that they claim is an ‘expert,’ but who is often a consultant hired by the insurance company themselves whose role is effectively to deny claims. These individuals are not necessarily doctors, nor do they always see you with their own eyes – sometimes they’ll attempt to deny simply based on a quick read of your file.

Insurance companies also claim that you need to be ‘totally disabled’ in order to receive LTD. This is a misleading term – you do not need to be in a coma or on life support to receive LTD. Illness can often be invisible, but that does not make it any less valid. This is especially problematic if the insurance company has hired surveillance in order to try and prove that you’re ‘not sick.’ It’s an unfair standard for illness, and one that tries to totally discount what your doctor has told you.

What can you do next?

While the insurance company may notify you of an option to appeal, it is crucial to seek out legal counsel before taking the next step. Any appeals are usually reviewed by the same individuals who denied the claim in the first place, so it is highly likely they will simply deny again, possibly for new reasons but potentially not. Remember that it is in an insurer’s best interests not to pay out claims, so it is unlikely that they’ll have a sudden change of heart. 

More importantly, the stress of navigating the appeals process on your own can often make your condition worse, or impede on your healing process. Common reasons for LTD applications such as chronic pain, fibromyalgia, and mental health issues can all be impacted by stress, so adding the stress of someone fighting with you that you’re not as sick as you know that you are can quite literally add insult to injury. 

There are times where it may make sense to proceed with an internal appeal in the event that the issue is something clerical. If you had missed a doctor’s appointment or a treatment appointment, or you had forgotten to provide a piece of documentation that you have in your possession, correcting that error can reopen your case. Be careful, however, about automatically expecting an approval just because you provided further documentation. 

If you have had your LTD application denied, make sure to hold onto the paperwork that has been provided, usually either a denial letter or a ‘termination’ letter in case your benefits were cancelled. This letter will usually spell out the reason you’ve been denied, as well as potentially what further documentation the insurance company is looking for. That letter will provide guidance to a lawyer should you choose to move forward with a claim.

Should you hire an LTD lawyer?

If you’re already stressed about your LTD denial, hiring a lawyer to commence a lawsuit against your insurance company may feel like a tremendous headache. However, there are several reasons that those who have been denied commonly proceed down the legal route instead of an internal appeal.

The reality is that claims against insurance companies for benefits denials are common, and have a much higher likelihood of success than an applicant going it alone. LTD lawyers focus specifically on this work, and they know the insurance companies inside and out. They know exactly what arguments to craft and what language to use to make the insurers take notice, and they are not afraid to litigate in order to get individuals what they deserve. 

If you are dealing with a serious medical condition and you’ve been denied LTD benefits, contact a lawyer who can help. The litigation team at Kung, Lo & Jia LLP is experienced in helping achieve a successful overturn of their LTD denial so that they can focus on the most important thing – getting better. Contact us today to set up a consultation.