When Your Long Term Disability Claim is Denied in Ontario

When Your Long Term Disability Claim is Denied in Ontario


When Your Long-Term Disability Insurance Claim Is Denied


You’ve been seriously injured in an accident. Every aspect of your life has been impacted, and you’re unable to go back to work. You’ve been able to access short-term disability benefits from your insurance provider, but they’ve nearly run their course, so you applied for long-term disability insurance coverage. Even though your condition hasn’t changed, you get a letter informing you that your insurance company is denying your claim. What should you do now?

First, you should know that insurance companies regularly deny long-term disability (LTD) claims — and it’s all about the money. A short-term disability claim usually lasts no longer than 180 days, something the insurance company is easily able to afford. But an LTD claim may last decades, costing the company millions of dollars, so it’s in their best interest to try to deny your claim. In fact, Canadian policyholders experience some of highest rates of denial in the world. The second thing you should know is that the clock begins running from the date on that denial letter, and you have a limited amount of time available to respond. Usually, this is 60 days from the date of the letter, and not from the date that you actually received the letter. And the most important thing you need to know is that having a good personal injury lawyer on your side can make a world of difference as to whether you will be able to access the compensation that you deserve.


The Appeals Process


The letter of denial should contain information that includes why your claim has been denied. Most often the denial will be based on your case manager’s assessment of your eligibility for benefits, your level of function, and whether or not you’ve been receiving appropriate medical treatment. Depending on what reasons are given, you may opt for one of two processes for appealing your insurance company’s decision, and your personal injury lawyer can advise you about them. One is an internal appeal, where you ask your insurance company to review your claim again. You will need to appeal in writing, provide new information about your case, and any tests or medical reports necessary must be done at your expense. With an internal appeal, employees of the insurance company will look at your claim again, but unfortunately, these types of appeals only very rarely reverse the original decision; the employees of the company have an interest in denying these expensive claims. There are, however, a few scenarios where it makes good sense to file an internal appeal; these might include situations when the insurance company is simply asking for more information, or if your appeal has been denied because you missed a medical appointment or a treatment.

An external appeal involves a neutral third party who reviews your claim and the insurance company’s counter arguments. Sometimes an external review involves a tribunal, other times it goes to court. With a tribunal, you will attend a hearing with a neutral adjudicator or arbitrator. This is a less formal process than going to court. At a tribunal, you will usually ask to have your benefits reinstated and claim for past benefits owed. If you have other aims, such as claiming for damages, you can take our case before a judge/jury in Ontario’s Superior Court. While this is a more complex process, going to court allows you to claim for past benefits, punitive damages, compensation for mental stress, and more. If you win or the case is settled, the insurance company will be forced to pay your legal fees.

If time is of the essence with regard to approaching deadlines, it may make sense to go directly to an external appeal without first attempting an internal appeal. Jumping to an external appeal first is also a good move if the insurance company’s reasons for denial include a technicality such as missing a deadline, or if the insurance company’s doctor has examined you and they seemingly have medical evidence that refutes your claim. Decisions about whether to file an internal or external appeal or whether to opt for a tribunal or a court appearance are best made in conjunction with a personal injury lawyer, who will understand the issues involved and the advantages and disadvantages of each choice.


Good Records


One important factor in any insurance claim is the quality of the documentation. Keep records of everything, even conversations or events that seem insignificant. Take notes from every call that you have with insurance company employees, and record them all in the same place, with dates and times, so that you have a complete timeline. Make sure that you also take notes about your injuries and your recovery. List every visit and conversation with medical professionals, keep records of all medications and treatments, and keep a journal that details your symptoms, including physical challenges, pain levels and psychological difficulties.

Contact a personal injury law firm today and meet with a lawyer who can help you to get the compensation you deserve!