Mental health conditions can affect every part of a person’s life — including their ability to work.
Depression, anxiety, post-traumatic stress disorder (PTSD), and other mental health conditions can make it difficult or sometimes impossible to meet the demands of a job. Yet employees who need to take time away from work often worry that their condition will not be taken as seriously as a physical illness.
For Canadians with workplace disability coverage, short-term disability (STD) and long-term disability (LTD) benefits may provide important income protection when a mental health condition prevents them from working. Unfortunately, mental health disability claims can also present particular challenges.
Here are five things employees should know.
- Mental Health Conditions Can Qualify for LTD Benefits
You do not necessarily need to have a physical injury or illness to qualify for long-term disability benefits.
Depending on the wording of your disability policy and your individual circumstances, conditions such as:
- Depression
- Anxiety disorders
- Post-traumatic stress disorder (PTSD)
- Bipolar disorder
- Panic disorder
- Obsessive-compulsive disorder (OCD)
- Other psychiatric and psychological conditions
may support an LTD claim.
The key question is generally not simply what diagnosis you have, but how your symptoms affect your ability to perform the essential duties of your occupation.
For example, severe anxiety may affect concentration, decision-making, memory and the ability to interact with colleagues or customers. Depression may cause fatigue, impaired concentration, sleep disturbance and difficulty maintaining a regular work schedule. PTSD can involve intrusive memories, hypervigilance, sleep problems and difficulty functioning in stressful environments.
These limitations can be disabling even though they may not be visible to other people.
- Medical Evidence Is Extremely Important
One of the challenges with mental health LTD claims is that there may not be an X-ray, MRI or blood test that establishes the severity of the condition. That does not mean the condition is not real or disabling.
However, insurers will typically examine the medical evidence closely. Your medical records should document not only your diagnosis, but also your symptoms, treatment and functional limitations.
Depending on your circumstances, relevant evidence may come from your family doctor, psychiatrist, psychologist, therapist or other treatment providers.
It is important to attend medical appointments and follow reasonable treatment recommendations. Gaps in treatment can sometimes be relied upon by insurers when assessing whether someone continues to meet the policy’s definition of disability.
The medical evidence should also explain how the condition affects your ability to work. A diagnosis alone may not tell the full story.
- Your Insurance Company May Require Ongoing Information
Being approved for LTD benefits does not necessarily mean those benefits will continue indefinitely.
Insurers commonly conduct periodic reviews and may request updated medical information. They may also ask about your treatment, symptoms, daily activities and possible return-to-work plans. Some insurers may arrange an independent medical examination or other assessment.
Employees should therefore continue to obtain appropriate treatment and ensure that their healthcare providers understand how their condition affects their ability to function in the workplace.
Be accurate when communicating with the insurer. Avoid minimizing your symptoms, but do not exaggerate them either.
Consistency between your medical records, disability forms and communications with the insurer can become important if the claim is later reviewed or disputed.
- Watch for the Change From “Own Occupation” to “Any Occupation”
Many LTD policies contain an important change in the definition of disability after a specified period, commonly around two years.
During the initial period, you may qualify for benefits if your condition prevents you from performing the essential duties of your own occupation.
After the change in definition, the insurer may consider whether you are capable of working in another occupation for which you are reasonably suited by factors such as your education, training and experience. This is sometimes referred to as the “change of definition” or “any occupation” period.
It can be a critical point in an LTD claim.
Someone may still be unable to return to their previous job but face an insurer’s argument that they are capable of performing different work.
Whether that position is justified depends on the policy wording, the medical evidence, the person’s functional limitations and the proposed alternative occupation.
Employees receiving LTD benefits should pay particular attention to correspondence from their insurer as they approach this stage of their claim.
- If Your LTD Claim Is Denied, Don’t Automatically Appeal to the Insurance Company
A denial letter can be devastating, particularly when you are already dealing with depression, anxiety, PTSD or another mental health condition and are unable to work.
But an insurer’s denial is not necessarily the final word.
Many denial letters tell claimants that they can appeal the decision by sending additional information to the insurance company. It may sound like the obvious next step.
Before submitting an internal appeal, consider speaking with a disability lawyer.
An internal appeal asks the same insurance company that denied your claim to reconsider its own decision. The appeal is handled within the insurer’s own process. It is not an independent court proceeding, and an internal appeal does not guarantee that a different decision-maker will reach a different conclusion.
In some cases, an appeal may make sense — particularly where the denial resulted from missing information that can readily be obtained and provided. But employees should not assume that they must go through one or more levels of internal appeal before they can consider legal action.
There are several reasons to be cautious.
First, the insurer has already reviewed the claim and decided not to pay benefits. Simply resubmitting much of the same information may result in the same decision.
Second, the appeal process can consume valuable time. An insurer may request further medical records, reports or assessments, and there may be multiple levels of review.
Most importantly, strict legal limitation periods may apply to your right to sue the insurer. Pursuing an internal appeal does not necessarily stop the limitation period from running.
That means a claimant can spend months pursuing the insurer’s appeal process while the legal deadline for bringing a lawsuit continues to approach.
For that reason, receiving an LTD denial should be treated as a signal to obtain legal advice — not simply as an instruction to begin the insurer’s appeal process.
A disability lawyer can review the denial letter, the policy and the medical evidence and advise whether there is a reason to pursue an appeal or whether it makes more sense to proceed with a legal claim.
Disability insurance claims in Canada are generally contractual claims, meaning that the wording of your LTD policy is extremely important. Limitation periods and other legal rules can also vary depending on the province and the circumstances of the claim.
If your LTD benefits have been denied or terminated, speak with a disability lawyer before appealing the insurer’s decision.
Mental Health Disabilities Are Real Disabilities
Mental health conditions can affect concentration, memory, energy, motivation, emotional regulation, attendance and the ability to cope with workplace stress.
For some people, those limitations make continuing to work unrealistic despite their best efforts.
If that happens, disability insurance may provide an important financial safety net.
The important thing is to understand your policy, obtain appropriate medical care, document how your condition affects your ability to work and take an LTD denial seriously.
If your claim is denied, don’t assume that the insurer’s internal appeal process is necessarily your best next step. Find out what your legal options are first.
Frequently Asked Questions
Can I get long-term disability benefits for depression or anxiety in Canada?
Yes, depending on your policy wording and how your symptoms affect your ability to perform your job.
A diagnosis is important, but the insurer will generally also consider the medical evidence concerning your symptoms, treatment, functional limitations and ability to perform the duties of your occupation.
Depression, anxiety, PTSD and other mental health conditions can cause significant functional limitations even when there is no physical injury that can be seen on an X-ray or other diagnostic test.
Can an insurance company deny LTD because there is no objective medical test for a mental health condition?
Mental health conditions do not always produce the type of objective test results associated with some physical illnesses or injuries. The absence of an X-ray, MRI or blood test does not necessarily mean that a person is not disabled.
However, insurers may closely examine the medical evidence supporting a mental health claim. This makes documentation of your symptoms, treatment, functional limitations and their impact on your ability to work particularly important.
What happens when my LTD claim shifts from “own occupation” to “any occupation”?
Many LTD policies change the definition of disability after a specified period, often around two years.
Instead of considering whether you can perform your own occupation, the insurer may consider whether you can perform another occupation for which you are reasonably suited by your education, training and experience.
This can be a particularly important stage in a mental health LTD claim because an insurer may reassess whether you remain disabled under the new definition.
The exact test depends on the wording of your policy.
Should I appeal if my LTD claim is denied?
Do not assume that an internal appeal is your best option simply because the insurance company has offered one.
Before submitting an appeal, consider speaking with a disability lawyer about the denial.
An internal appeal asks the insurer to reconsider its own decision. If the insurer already has the relevant medical evidence, providing substantially the same information again may not change the result.
There is another important concern: an internal appeal does not necessarily stop the legal limitation period for suing the insurer from running.
You may also not be required to exhaust every level of the insurer’s internal appeal process before taking legal action.
There are circumstances where an appeal can make sense, particularly where important medical evidence was missing from the original application. But that decision should be made after considering all of your options rather than simply following the instructions in the insurer’s denial letter.
If your LTD claim has been denied, consider getting legal advice before you appeal.
Has Your Mental Health LTD Claim Been Denied?
Kotak Personal Injury Law represents individuals whose short-term and long-term disability benefits have been denied or terminated.
Our disability lawyers have experience with claims involving depression, anxiety, PTSD and other mental health conditions, and we understand the challenges that can arise when an insurer questions a condition that cannot always be seen.
If your LTD or STD benefits have been denied or cut off, don’t assume you have to appeal the insurance company’s decision before speaking with a lawyer.
Contact Kotak Law for a free consultation. We can review the denial and help you understand your legal options before you decide what to do next.
This article provides general information only and is not legal advice. Disability insurance policies differ, and the rights available in any particular case depend on the policy wording, applicable law and individual circumstances.
