People suffering from debilitating conditions that affect their ability to work are often shocked when their disability insurer denies their claim for long-term disability benefits.
For months, sometimes years, their symptoms have persisted or deteriorated to the point that they can no longer carry out the duties of their job. Their doctor prescribes a treatment plan, including time off work, and provides their insurance company with medical evidence of their condition and its limitations, yet their claim is denied.
Receiving a denial letter from the insurance company is devastating. Policyholders pay their premiums and expect to have coverage if an illness or injury makes it impossible for them to work. For many, a denial of benefits not only puts them in a precarious financial position; it often exacerbates their symptoms, including increased levels of stress and anxiety. By the time clients come to us, many have had to borrow money or tap into retirement savings just to pay their rent, mortgage and other bills.
Denial of legitimate claims for long-term disability happens more commonly than people think. While disability insurance companies don’t share statistics, as a lawyer who practises in this area, we hear stories every day from clients battling depression, anxiety, chronic pain, cancer, cardiovascular conditions, neurological disorders and other chronic conditions who have been denied insurance benefits.
In this post, I’ll explain the most common reasons claims are denied, why appealing the insurer’s decision through their internal appeal process is a waste of time and how an experienced long term disability lawyer is your best shot at a successful outcome.
Why are long term disability claims denied?
There are four main reasons long-term disability claims are denied:
- insufficient medical evidence
- failure to meet the test of total disability
- proof that your disability is not as severe as the applicant claims
- the insurance company’s independent medical examiner has determined that you can work. This scenario mostly happens with an ongoing claim, where the insurance company feels the claimant is exaggerating their symptoms.
Let’s look at the two main reasons in more detail and I’ll demonstrate the strategy and tactics I leverage to challenge them.
Insufficient medical evidence: Disability insurers look for evidence in an application for benefits. Claimants must demonstrate — by way of medical evidence — that their condition renders them unable to work. The more medical documentation you provide, the better.
One of the required forms in the application for disability benefits is the physician’s statement. Often, claims are denied because the doctor has provided limited or incomplete information. They may state that the patient is unable to work, but they don’t provide enough detail of their specific limitations and the impact it has on their day-to-day functional ability.
Denials are more common when it comes to claims for mental illness, even though one in three workplace disability claims in Canada is related to a mental health issue. Studies show that, in any given week, at least half a million Canadian workers can’t work because of a mental illness.
Unlike physical impairments that can be demonstrated through tests such as an MRI or CT scan, the diagnosis of psychological conditions such as anxiety, depression and stress are often based on self-reporting of symptoms.
In these types of cases, the best course of action is a referral from your family doctor to a psychologist or psychiatrist, which can be challenging given the long wait times for specialists. The average wait time for adult mental health counselling and treatment in Ontario is 118 days, reports CBC.
What’s important is that, by requesting the referral and following up on it, you’re demonstrating that you are taking all the necessary steps to help yourself. When the insurance company sees you’re seeking or receiving active treatment from a specialist, it tends to carry more weight.
Physician’s statement a critical component
When we take on a client’s case, our priority is to ensure that the medical evidence your doctor provides aligns with the test for total disability as laid out in the policy. This is critical. Each policy is unique and the requirements to prove disability may be different.
Doctors don’t spend their days studying insurance policies. In the absence of clear guidance on what the insurance company requires to prove disability, most assume it’s enough to simply state that a person can’t work. But it’s not enough. As your long term disability lawyer, we provide your doctor with clear direction on the information the insurer needs. We commission a narrative report from your physician that explicitly details how your condition impacts your life, including your ability to work.
You don’t meet the test of total disability: For many of our clients, the overriding reason in the insurance company’s denial letter is that the medical records do not indicate the claimant meets the criteria for total disability.
Every insurance policy has specific terminology for how “total disability” is defined, but in general, long-term disability means a person can’t perform the essential elements of their own job or any job for which they are trained or experienced.
Something to keep in mind is that, after you file a disability claim, a case manager from the disability insurer is assigned to your case. They assess your claim and approve or deny it. Often with denials, we discover errors in how the policy — or the documentation supplied by the claimant — has been interpreted by case managers.
When we take on a case, we relieve the burden of dealing with the insurance company. Insurance policies are full of legalese and not easily understood by the average person. Having a long term disability lawyer review the policy to determine if there’s a disconnect between what’s required to demonstrate disability versus what’s been provided can make all the difference.
What can I do if my claim is denied?
If your claim has been denied by the insurance company, it doesn’t mean you can’t challenge the decision and reach a successful outcome in your case. Our recommendation is to seek legal advice as soon as you’re denied.
In its denial, the insurance company will invite you to appeal its decision through its internal process, but in our experience, it’s a waste of time and can sometimes work to your disadvantage. Going through the process takes months and rarely results in a reversal of the decision.
Another important point to keep in mind is that there’s a limitation period of two years in which you can file a lawsuit against the insurance company.
While your claim is in dispute, the following are some important actions you can take:
- See your doctor regularly and report any changes in your condition and abilities
- Attend all medical appointments, including referrals to other medical and rehabilitation specialists
- Keep a journal to document your symptoms and limitations and make note of any significant changes as they occur
- Understand that you may be under surveillance by the insurance company, both in person and through your online activity, including social media posts.
How can a long term disability lawyer help with a denial?
Fighting an insurance company on your own can be overwhelming. Policyholders don’t have the same resources as insurance companies, and they often feel intimated and ill-equipped to continue fighting after receiving a denial.
Hiring a disability lawyer helps you level the playing field; we navigate these complex cases every day and understand how to effectively argue your case. When we review your file, we will give you a straightforward answer as to whether it’s in your best interests to pursue legal action.
Our goal is to understand where the evidence is lacking, determine if there’s been a misinterpretation of the policy and supply the required documentation to the insurance company. In some cases, this involves speaking to your doctor, if you agree, and having you assessed by other professionals who provide a report on your functional limitations.
Once a statement of claim is issued, the matter is moved from a case to manager to the insurance company’s legal department, and the insurer tends the view the claim in a new light.
At Edwards Pollard, our lawyers for life insurance and disability lawyers have fought many of the top disability insurance companies including Sun Life, Manulife, Fenchurch, Standard Life, RBC, Co-operators Life, Desjardins, Great West Life and London Life and have successfully obtained benefits for our clients. Our job is to advocate for our clients’ rights, and we take that responsibility seriously.
If you have been denied benefits and want to understand your rights and options to challenge it, give me a call.