Dealing with a workplace disability is difficult enough without the distraction of an argument with your insurer over your long-term disability (LTD) benefits application.
In my many years of practice as a long-term disability lawyer in Oakville, I have seen far too many disabled workers whose LTD benefits were denied or delayed — not because of the substance of their injuries, but because of avoidable problems with their applications — causing unnecessary stress and gaps in income while the issues are rectified.
Following is a list of common mistakes claimants should avoid to boost their chances of an error-free LTD benefits application.
1. Disregarding your policy
An insurance policy is the single most important document where any LTD claim is concerned. It governs the relationship between an insured person and their insurer, and its contents will determine whether or not a worker qualifies for benefits.
Claimants don’t need to know their LTD policies inside and out — the legalese would probably drive you to distraction — but there are some crucial details to review before submitting an application for benefits.
For example, most group LTD policies require injured workers to show that they are totally disabled either from performing the essential tasks of either their “own occupation,” or from employment in “any occupation” they could become qualified for, to be entitled to benefits.
Generally, the “own occupation” test applies for the first two years of a claim, before switching to the more stringent “any occupation” test, but individual policies may differ, and claimants must ensure they are applying under the correct category.
In addition, each policy will have its own exclusions limiting or barring coverage in certain situations. For example, it’s not unusual for an insurer to include policy provisions denying coverage for pre-existing conditions or claims based exclusively on psychological impairments.
2. Keeping your doctor in the dark
Few people relish a visit to the doctor, but this is essential if you plan on making an application for LTD benefits.
When an employee claims they are disabled from working, insurers want to see supporting medical evidence, and a note from your family doctor confirming that you need some time off is not going to cut it.
These kinds of holes in an LTD application may not result in an outright denial, but they will certainly delay a case while insurers seek more fulsome answers from the claimant and their treating physicians.
The more information you can give your treating medical professionals about the nature of your job, your health issues, and even the terms of your LTD insurance, the more accurate and detailed they can be in their reports about your struggles and how they impact your ability to do your job.
If you see multiple treatment providers, such as a physiotherapist, psychologist or other specialists, you may also have to act as coordinator to ensure all available records and clinical notes are included as part of your application.
3. Ignoring medical advice
Going to the trouble of seeing medical professionals and having your injuries assessed is only half the job for LTD claimants. To maximize the chances of having their application for benefits approved, they must also follow through with any treatment recommendations they receive.
In addition to aiding with rehabilitation efforts, sticking to a treatment plan prevents claimants from falling foul of policy exclusions that kick in when an injured worker fails to take advantage of a treatment made available to them.
4. Delaying your application
Employees who are lucky enough to qualify for short-term disability (STD) payments from their employer should not let themselves be lulled into a false sense of security regarding LTD coverage.
In an ideal world, the transition from STD to LTD would be swift and smooth, leaving no gap in the claimant’s income stream. But in reality, you need to build in some time for the gathering of supporting documents, as well as the internal bureaucracy of your LTD insurer. You should not be surprised to wait somewhere between six and eight weeks just for them to review an application and adjudicate on it.
There is no reason to wait until your STD benefits expire before making an LTD claim — workers often have a sense for whether or not their injuries will persist, long before they get to the end of the STD period, and the earlier you make a start, the sooner you will get a decision.
5. Failing to update your insurer
It’s important to remember that your application for LTD benefits is just a snapshot in time. Insurers will want regular updates from you and your medical professionals on your condition, to ensure that you still meet whichever test for coverage applies in your case.
To keep their benefits flowing without interruption, claimants should keep their contact at the LTD insurance provider — often a claims adjuster — informed of any changes in their health and send them fresh records from new or existing treatment providers as they become available.
If you are having trouble applying for LTD benefits or your insurer has denied your claim for benefits, feel free to contact me or another member of the team at Edwards Pollard. Our long-term disability lawyers will be happy to help you.