Long-Term Disability Appeals
Submitting a long-term disability (LTD) insurance claim can be much more challenging than buying a policy. While insurance companies are eager to sell policies and collect premiums, the point at which you must depend on your coverage is the first of many when they will examine whether to grant you benefits.
Unfortunately, this scrutiny can result in the denial or termination of your benefits, and even repeated efforts on your part to collect what you fairly deserve may not succeed. You may be unsure of what to do next as your financial obligations quickly add up.
Fortunately, in most instances, the legal system offers a path to fair compensation and our long-term disability lawyers can help. Contact us for a free consultation to learn more.
What happens in an internal LTD appeal?
If your insurer denies your LTD claim, it must offer you an option to appeal, or dispute, the decision. The appeals process is established by the insurance company, meaning all terms and rules, such as grounds for reconsidering denial, deadlines, number of appeals possible, and acceptable evidence are largely in their control. Because it is internal, each insurance company’s process may have different requirements, much as individual policies differ.
Your goal is the same regardless of who insures you, or whether the plan is paid by you or your employer. The appeal is an opportunity for you to present new, compelling evidence to the insurance company of your medical condition as well as its effect on your capacity to carry out labour. (Often, the “any occupation test” rather than the “own occupation test” will apply. This means that the insurer can rule against you as long as you can still do any job that you are reasonably qualified for, not just the occupation you had before claiming disability.) To accompany this evidence, you will need to write an appeal letter that clearly lays out the reasons that your denial was wrong.
Similarly to if you were preparing for a trial, you must offer new evidence demonstrating that you have a health condition like an illness or injury, whether mental or physical. Additionally, you must establish that your condition (or conditions) prevent you from working. Diagnosis of a specific disease or injury (for example, a heart attack) is not necessarily required but you will still need to show that your medical symptoms interfere with your ability to function at work and perform the tasks demanded of you.
Most often, this evidence will consist of reports and testimony by healthcare professionals who have examined, diagnosed, and/or treated you. Statements from vocational experts on your capabilities in a workplace setting given your condition and from your employer about your job duties may also form part of your case.
A long-term disabiltiy lawyer can look at the specific circumstances of your claim and advise you of your options to proceed. In some cases, they may recommend skipping an internal appeal and pursuing litigation right away. Sometimes, however, an internal appeal is appropriate. In addition, legal counsel offers fresh eyes and valuable knowledge to help spot weaknesses in your insurer’s arguments.
How long does the long-term disability appeal process take in Canada?
Your initial application for long-term disability benefits may have taken several weeks to process. As part of the application, your insurer will demand in-depth documentation proving your income, medical condition and the extent of its disabling effect on your working ability, and your job duties. It may also (and will very likely) order additional assessments that confirm your medical condition and its effect on your ability to work. These could include an independent medical examination (IME) by a third-party doctor who the insurance company pays.
Your insurer will then make a decision and notify you of it. If it turns down coverage, and you choose to appeal internally, the process of requesting, gathering and presenting evidence will continue. The appeals process may take as many as 8 months to complete.
We recommend any insured parties co-operate as much as they can with demands from the insurance company for information and at an IME or other assessments. Failure to do so may be interpreted as reason to deny or terminate a claim. Your insurance company may continue to turn down long-term disability (LTD) coverage to you and stand by its initial reasons for denial, even if you have pursued all internal appeals.
Whatever appeals you might choose to pursue, the insurance company’s letter of denial will lay out the reasons for turning down your claim (or ending your benefits, if you were already receiving them). If you have not yet received such a letter, you can request a detailed explanation for the denial from your insurer and they must provide one. You can also ask for a detailed explanation of any part of the denial that you do not understand. This document will be very useful if you later dispute the insurance company’s findings. Read the letter of denial very carefully.
Professional legal support can strengthen your long-term disabiltiy claim and ease your application process, but it is especially useful when you want to file a lawsuit against your insurer and no longer have recourse through your insurer’s in-house processes.
Why should I take legal action against my insurer for denying my appeal?
The statute of limitations to make a legal claim on your LTD insurance is two years, for which the clock starts running from the date of initial denial. Taking the time to launch an internal appeal and wait for the outcome narrows your window to make such a claim. It uses up other valuable resources, including your energy, as well. It is possible for you to prepare an LTD appeal by yourself, but you must pay careful attention to support all aspects of your claim. You must also follow any deadlines and handle any communications with your insurer.
If the denial is due to a technicality, such as missing documentation (for example, a doctor’s report) that you can provide fairly easily, then an internal appeal may be appropriate. Otherwise, such appeals do not often succeed. If you have not yet appealed a denial of benefits, you may wish to take your dispute directly to the court system.
Insurance companies could use information from an appeal to prepare a case against you in anticipation of you filing a legal claim. Additionally, even if your case does not proceed to court (as very few do), any negotiations that take place will do so according to the law and the legal system’s rules rather than those set by your insurer.
Our long-term disability lawyers will negotiate with your insurance company and argue forcefully for you in court if necessary should you retain us as your counsel. If successful, your insurer may offer a lump-sum settlement or to reinstate your long-term disability benefits. Which option is best is ultimately up to you, but keep in mind that your insurer could try to cut off your benefits again if it reinstates them. You may also be subject to future medical assessments, typically on an annual basis. A lump sum could be smaller in dollar value than regular benefits, but it provides certainty and ends your relationship with the insurer.
What other financial support can I pursue while my lawsuit progresses?
Financial hardship is common during the wait for an long-term disabiltiy claim to be resolved. If you have taken time off work due to your disability, your expenses will keep adding up despite your lack of earnings. This can in turn increase your stress and pressure to return to the labour market, potentially before you are ready medically.
Thankfully, apart from your LTD insurance through a group employee or private plan, there are also long-term government disability benefits that you may qualify for.
The Canada Pension Plan disability benefit, commonly referred to as CPP-D, is one such benefit, paid monthly. Like LTD insurance coverage, you are eligible if you have a mental or physical disability that regularly stops you from doing any type of labour and is of long-term, indefinite duration (or is likely to result in death). You must also be less than 65 and have contributed enough to the Canada Pension Plan to qualify. If you apply for and receive CPP-D payments, and your children are still dependents (under 18 or between the ages of 18 and 25 but attending school full-time), they are also qualified to receive a monthly CPP children’s benefit.
Our long-term disability lawyers frequently recommend applying for these other coverage sources. Aside from offering some income in lieu of your insurance, acceptance into these programs will bolster your LTD case against your insurer, since it will naturally be more difficult for them to argue your lack of disability. Even if your long-term disability insurance claim is ultimately successful, these programs could provide important additional support to you and help cover your financial needs.
Contact our long-term disability lawyers for legal help with your long-term disability appeal
Preszler Injury Lawyers was founded in 1959. Since then, we have helped thousands of clients to make their insurers pay what they owe. Today, our firm is pleased to serve long-term disability clients across the country. If you or a loved one have had their LTD appeal denied, contact our long-term disability lawyers for help. Our initial consultation is free, and you don’t pay us anything until we recover compensation for you.
*Please note the content in this article is only intended to be a general overview on this topic and not intended to be taken as legal advice. Please speak with a long-term disability lawyer for specific legal advice as each situation is unique.