Getting approved for long-term disability benefits is only part of the battle for employees who are unable to work as a result of an illness or injury.
The sad reality is that claimants need to steel themselves for further fights with their insurer at various stages of the process — often years after receiving their first benefits — in order to show that they’re still disabled from working.
It can be exhausting to get over the hurdles that insurance companies place in the way of continued coverage, and for many benefit recipients, the constant threat of termination hovering over them erodes the financial and emotional security that a group disability insurance plan is supposed to provide.
Recently, our firm represented a 41-year-old man who worked at an Ontario department store in a lawsuit filed against his disability insurance company. In the post, you will learn about his journey and the steps we took with him to successfully resolve his claim.
How it started
Jim (not his real name) had suffered from vertigo long before the condition became debilitating to his work as a salesperson at a department store. However, several years ago, his symptoms intensified, as daily bouts of migraine, vomiting and insomnia began interfering with his ability to carry out his duties.
According to the University of California at San Francisco, as many as 40 per cent of adults can expect to suffer at least once in their life from vertigo, a condition that typically manifests as dizziness or a sense of spinning that affects balance and coordination. Women are slightly more likely to be affected than men, and while the cause is often hard to detect, it can sometimes be attributed to neurological disorders. For Jim, the onset of more serious symptoms was compounded by severe anxiety and depression, and his claim for long-term disability was approved by the group insurance provided through his employment.
Disability benefits terminated
When Jim’s benefits were terminated after two years, he became the victim of a change in the test for coverage that happens under virtually all long-term disability (LTD) group policies after 24 months.
For the first two years, workers must show that they are totally disabled from performing the essential tasks of their “own occupation” to receive benefits. After that point, the policy wording typically requires an insured person to be totally disabled from employment in “any occupation” for which they are “qualified or may reasonably become qualified by training, education or experience.”
The new test is much more stringent since it’s no longer the specific tasks of your own job that are at issue. Instead, the question becomes about your suitability for any type of work, which makes the two-year mark a popular time for insurers to seize the opportunity and terminate benefits.
Functional ability assessment
Ahead of the termination of Jim’s benefits, his insurer arranged for him to attend a functional ability assessment, which is designed to test his skills with a view to matching them with potential alternative work.
They may sound like a great idea in theory, but in practice, the main purpose of these assessments is to boost an insurer’s case for termination by purporting to show that claimants have other options for a return to work.
Jim was unable to complete the assessment after suffering a vertigo attack during the session that caused him to fall off the furniture. Incredibly, the insurer’s report managed to omit this critical detail, putting the early termination of the examination down to “safety” issues.
Rather than proceeding with a second assessment, the insurer had one of its own doctors analyze Jim’s ability to work based on a review of his medical records, without ever actually meeting him in person. In a result that will come as no surprise to those who know how insurance companies operate, the report concluded that despite his vertigo, Jim should be able to return to work.
The report also provided a list of completely inappropriate work options for Jim that bore no relation to his current or potential future skillset. Unfortunately, his limited education and lack of computer skills mean that he is not well suited to the types of sedentary desk jobs that insurers usually suggest in these instances.
In addition, the insurance company made no attempt to explain how Jim could perform any of these jobs, considering that he is incapable of sustaining any sort of standing or sitting position for long periods.
Suing the disability insurer
When Jim told came to us for help and told us his story, we had several serious concerns about how his LTD benefits were terminated, and we filed a lawsuit on his behalf against the insurer.
In the meantime, we obtained a report from Jim’s family doctor, who was able to lay out all his various ailments and the medication he had taken to combat these medical issues, which included his severe vertigo and chronic depression.
We were also able to gather records and opinions from medical providers about other treatments Jim had pursued over the years, including trips to headache clinics, neurological consultations and psychotherapy.
How we resolved Jim’s case
In Jim’s case, the insurer agreed to our request for early mediation, and we set to work preparing him on how to communicate the impact his vertigo and related medical issues had on his day-to-day functional abilities.
Our mediation brief explained in detail the unfairness of the termination, built as it was on a shaky foundation without any credible evidence or facts to support it.
On the mediation day itself, Jim gave a powerful account of his struggle over the past few years, and we were able to reach an agreement with the insurer that will deliver him a significant amount of money to compensate him well into the future for the termination of his benefits.
Equally important, Jim’s settlement allows him to focus on his health and recovery without having to worry about the hassle of dealing with his insurer.
It’s for clients like Jim that we’re in the practice of disability law. His story shows that the fight is never over with your insurance company, even after your LTD claim has been approved. Months and years down the line, they’ll have new hoops for you to jump through to continue coverage, backed up by the constant threat of termination. Just remember that you have a right to dispute an insurance company’s decision, and with the help of an experienced disability lawyer to guide you through the process, you can fight back.
If your disability insurance claim has been denied or cut off and you’re considering hiring a lawyer, our blog post has helpful tips and questions you should ask a lawyer before hiring one.
KOTAK PERSONAL INJURY LAW/DISABILITY LAWYERS CAN HELP YOU
We understand that being denied short-term disability or long-term disability benefits can be devastating. Your time to fight your disability insurance company is limited. Please do not delay in calling a short- and long-term disability claim lawyer at Kotak Personal Injury Law. We have successfully sued numerous disability insurance companies including Manulife, Sunlife, Desjardins, Cigna, Great-West Life, Equitable Life, Empire Life, London Life, Blue Cross, AIG, SSQ, RBC, Industrial Alliance, Canada Life, Fenchurch, OTIP, Teachers Life and more.
Call your trusted long-term disability lawyers at 1-888-GOKOTAK or (416) 816-1500. Our consultation is free, and we don’t get paid until you do. We represent disabled people throughout Ontario including Toronto, Mississauga, Brampton, Milton, Georgetown, Orangeville, Oakville, Burlington, Hamilton, St. Catharines, Niagara Falls, Stoney Creek, Kitchener/Waterloo, Cambridge, London, Windsor, Markham, Pickering, Oshawa, Peterborough, Fort Erie, Keswick, Kingston, Ottawa, Barrie, Timmins and other locations.