Long-term disability insurance is an income replacement benefit that pays all or some of your regular income if you are ill or injured and can no longer work. While this insurance is designed to provide peace of mind, an insurance company can deny or terminate your LTD claim, which can be devastating when you are already dealing with an unexpected illness or accident that leaves you unable to work and earn an income.
If you have to make an LTD claim, it is crucial to read your policy to understand the test for disability benefits and what your policy covers. There are several reasons your claim might be denied or terminated, and while it can feel like an uphill battle to appeal that decision, an experienced long-term disability lawyer can guide you through the process. Because our firm has fought many of the top disability insurance companies in Oakville and successfully obtained benefits for our clients, we have seen a few common pitfalls.
Gather your documents
To pursue an LTD claim, you need to have coverage either through your employee benefits or privately purchased insurance. Read your policy to understand what documentation and paperwork you need to submit for a decision to be made by your insurer. Although policies vary, be prepared to have sufficient medical documentation to justify being off work for medical reasons.
As soon as you know that you need to go off work, reach out to your human resources department and find out what forms you need to fill out. The more documents you can provide with your initial application, the more likely you will receive an initial decision. If they require additional information, it just draws out the process.
Requirements of the doctor’s note
A common problem I see is when a claimant has a short note from their doctor. A two-sentence letter simply stating that you need to be off work because of your illness or injury is not helpful. Instead, your treatment provider should document that they support you being off work and explain their reasoning.
The more supporting documents, the better. If there are test results or diagnostic imaging such as X-rays, those can support the claim. If you see a specialist or other treatment providers, it will significantly benefit your claim if they also provide records and reports.
There has been an increase in psychological disability denials, claims that deal with stress, depression, or anxiety. In those instances, the focus is on function because one person who has depression may continue working while someone else may not. With those types of claims, a denial can rest on the strength of the reports of treating medical providers, including psychiatrists or psychologists.
Some healthcare providers are supportive, but others brush off their patients and don’t want to get involved in case it ends up in litigation. Once an experienced disability insurance lawyer from Oakville gets involved in your claim, they can guide your doctor and explain what needs to be in their report.
Fighting a denial with your long-term disability lawyer
If your application is denied, your insurer will inform you of your ability to appeal. I always advise claimants to speak with a lawyer before appealing through the insurance company’s internal process. Unless you were denied because you forgot to include some significant medical documentation, appealing does little to change their mind and will delay your file for months.
When a client reaches out to me after their claim is denied, we set up a meeting to review the policy’s wording and any records, reports, or notes submitted with the application. If it looks like the denial or termination of benefits was not proper, we will request the entire claim’s file.
This file — which can include emails or notes of phone calls — is reviewed with a fine-tooth comb. Often, we can identify some inconspicuous errors that were made that will strengthen your ability to fight the denial.
Sometimes a claims analyst will make conclusions about your ability to work or fail to consider the opinion of treating practitioners without referring your file for an internal assessment conducted by a psychologist or a doctor.
Starting a legal case
If, after reviewing the claims file, it appears there was a wrongful denial or termination, we will draft a Statement of Claim, which formally starts a lawsuit. Once the Statement of Claim is issued, the insurance company or employer — whoever was denying the benefits — will file a Statement of Defence. Both sides exchange further productions, including updated records and narrative reports from the treatment providers to strengthen the case.
At this point, parties schedule a mediation to try and settle. If mediation fails, there will be examinations for discovery, where your lawyer questions the insurer and the insurance company’s lawyer will ask you questions. Your lawyer should spend time preparing you for that process so you feel confident providing answers. And then, if parties cannot settle, your lawyer will obtain experts for the lawsuit and ask for a pre-trial conference, where a judge will give their opinion on the strength of the case. The last stage, of course, is a trial.
There are opportunities to settle at any point — from the beginning of the claim until the start of the trial. But you need to ensure that you are working with a law firm that will take your case to trial if the insurance company doesn’t settle. It’s worth noting that more than 90 per cent of these types of cases will settle at some point, and going to court is rare. This is why it’s essential to speak with a lawyer early on to get advice about your LTD denial before appealing through the insurance company.
Let us be your long-term disability lawyers!
If your claim for disability benefits has been denied or terminated and you would like an opinion on your case, call our office at (289) 529-0404 to schedule a consultation.