Getting a medical diagnosis is only half the battle for many long-term disability (LTD) claimants, says Toronto disability lawyer Nainesh Kotak.
Although a physician’s statement about the worker’s condition and the prognosis is a key part of a long-term disability claim, Kotak, the principal at Kotak Personal Injury Law, says insurers are rarely happy to take the word of a single doctor that the problem warrants the payment of benefits.
In fact, he says there’s a good chance that an insurer will answer back with a denial using their three favourite words: “insufficient medical evidence.”
“It’s a catch-all phrase that basically means they haven’t been convinced that the person is lacking in function as a result of their disability,” Kotak says. “It’s one of the easiest ways for them to deny claims, because it’s a very subjective assessment, and it’s often done in the face of letters and reports from doctors saying that the person can not work.”
Uphill battle for claimants
Those with newer or rarer medical issues are more likely to run into difficulties establishing their LTD claim, as a Toronto woman recently learned after apparently developing “long-haul” COVID-19.
The woman told CTV News that her condition originally improved after she suffered symptoms early in the pandemic, but that she has since been struck by a lengthy period of fatigue, heart issues and breathing difficulties that have made working impossible.
Despite undergoing many medical tests, her LTD insurer denied her claim, leaving her and her husband to dig into their savings and even think about selling their house to get by.
“Fighting this debilitating illness is really only a small part of a much bigger struggle … we have to plan for the worst now,” the woman told the news outlet.
Insurers demand ongoing proof of disability
An outright denial at the outset isn’t the only way an insurer will question a claimant’s medical evidence, Kotak says.
Even after LTD benefits have been approved, he explains that insurers will continue to ask for medical evidence from disabled workers to support their claim on an ongoing basis.
The chance of termination peaks after two years in receipt of benefits, according to Kotak, who explains that this is when the test for coverage changes under most policies.
For the first two years, claimants are covered if they can convince their insurers that they are unable to perform the duties of their own job because of their disability.
Higher threshold after two years
But after two years, the test shifts, and policyholders are required to show that they are totally disabled from performing any type of work to continue receiving benefits.
“It’s a higher bar to meet,” says Kotak, noting that workers may be required to perform different work from their original duties, so long as they are qualified for it in terms of education, skills or experience.
For example, a person physically disabled by an injury may be able to perform lighter work or sedentary tasks, he adds.
The lawyer helps resolve claims efficiently
Whenever a denial or termination comes, LTD claimants must move quickly to respond to minimize the chances of an interruption in payments, Kotak says.
“When people are off work, it’s not only their livelihood that is in jeopardy: it’s their home and their family relationships. It’s not a time for hesitation,” he adds.
Kotak recommends reaching out to a lawyer as early in the process as possible.
“When you get a lawyer involved, all of the pressure and stress of dealing with the calls and correspondence of the insurer is taken away, because we handle that burden,” he says.
In addition, he says LTD claimants who opt to go it alone are often distracted by the insurers’ offers of an internal appeal.
“What you inevitably find if the person uses the internal appeal route is they spend months trying to get new letters from their doctors, only to end up in exactly the same position, because they’re denied again,” Kotak says. “Insurers very rarely overturn their own decisions.”
He prefers to proceed quickly to litigation, which he says focuses on the minds of everyone involved.
“When we quickly get a statement of claim issued, the file is moved from the case manager level of the insurer to a legal level, and you get a truly fresh set of eyes looking at the matter,” Kotak says.
If you decide to work with a disability lawyer to handle your claim, he suggests reading the firm’s blog post for tips and key questions to 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.
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