The critical role of medical evidence in LTD claims

While no two applications for long-term disability (LTD) benefits are the same, they usually share a common decisive factor: medical evidence.

To boost your chances of success, here are some factors for LTD claimants to consider to make the most of their medical evidence with the help of a long-term disability lawyer.

Policy focus

A brief doctor’s note may be enough for your employer to give you a couple of weeks off work, or maybe even longer. But there is no chance it will convince an insurer that you are entitled to LTD benefits.

When it comes to medical evidence, your focus — just like your insurer’s — must be on the text of your group policy, which governs the relationship between the two of you.

To put your best foot forward, you may have to educate your family physician or any other treating practitioners on the precise terms of your insurance policy, so that they know exactly what it takes to meet the test for disability and can frame their notes and reports with those requirements in mind.

Individual group LTD policies will differ, but typically, they require injured workers to show that they are totally disabled from performing the essential tasks of 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 a more stringent test requiring an insured person to be totally disabled from “gainful employment” in “any occupation.”

Diagnosis limitations

LTD policies do not generally require claimants to identify a specific condition to receive benefits, but attaching a label to your problem can be helpful for both the insurance company and the insured person as they attempt to understand the nature of the issue, as well as possible treatment options. 

However, obtaining a diagnosis should not be your sole aim when seeing a medical professional, as it is rarely enough on its own to sustain an application for LTD benefits. For example, the CBC recently reported on a financial advisor’s forced off work by burnout, only to discover that their insurer did not recognize the condition as one that qualifies for disability coverage.  

A successful application developed with a long-term disability lawyer for LTD benefits will contain medical evidence showing how the claimant’s health condition — however labelled — affects their ability to function at work. It may help your treating practitioners to make that connection if you can fill them in on the nature of your job, your health issues and any difficulties they are causing you, whether at home or in the workplace.

Types of medical evidence

Medical evidence in an LTD case can come from a wide variety of sources. Here are some of the main types that you can expect to encounter during the course of your matter: 

  • Narrative reports: You should try to obtain detailed narrative reports from all treatment providers, which may include your family doctor and any medical specialists you may have been referred to, such as occupational therapists, chiropractors and physical therapists. It’s important to be mindful of any additional costs associated with this kind of report, but the more you can provide, the better it will be for your case.
  • Tending physician statements: These forms are often sent out by insurers for your treatment providers to fill out. Although they typically allow for check-box answers, you should ask your doctor to give as much information as possible about your condition and any effect on your day-to-day functioning in the spaces provided. 
  • Diagnostic testing: Where physical injuries are involved, any MRIs, ultrasounds and X-rays taken by your treating physicians could be useful evidence in your LTD case. Even at an early stage in proceedings, evidence of these tests could be important as they show your insurer that you are taking active steps to investigate and remedy your medical issues. 
  • Clinical notes: Your insurer will want to see medical records covering the period at issue. Again, a common stumbling block for LTD claimants involves omitting evidence from key treatment providers. Make sure your long-term disability lawyer has a complete list of all the medical professionals you have seen — including at walk-in clinics or during ER visits that may not spring immediately to mind — so that you can provide a more fulsome picture of your medical history.

Legal Guidance

The path to a successful long-term disability claim heavily relies on the quality and comprehensiveness of your medical evidence. Remember, it’s not just about having a diagnosis; it’s about demonstrating how your medical condition impacts your ability to function in your job and daily life.

By understanding the terms of your insurance policy, educating your treating practitioners and providing a well-rounded collection of medical evidence, you can enhance your chances of a favourable outcome.

If you or someone you know is navigating the complexities of a long-term disability claim and would like legal guidance from a long-term disability lawyer in Oakville, please contact the team at Edwards Pollard LLP.

Request a Call