Many insurers treat long term disability benefits as a wager. Insurance companies know that many individuals suffer from a long term disability but do not file a claim – and that many of those that do file a claim will give up if their claim is denied.
But if your claim has been denied, you shouldn’t give up.
Kotak Law has provided assistance to countless Orangeville clients suffering from disabilities and from insurance companies that refuse to pay benefits. We help you take charge of your claim, and win the long term disability benefits that you deserve.
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Orangeville Disability Cases in the News
APPLYING FOR LONG-TERM DISABILITY BENEFITS
Young adults in Orangeville are at far greater risk of becoming disabled due to injury or illness, than they are of passing away before reaching the age of 65. If someone suffers an illness or injury that extends beyond ‘the temporary’, long-term disability coverage provides the important function of allowing a person to focus on their recovery, rather than having to worry about making ends meet and how to pay for needed rehabilitation treatments.
If you have long-term disability coverage and are suffering from an illness or injury that will prevent you from returning to work, you will not be paid LTD payments until the waiting period specified in your group or individual insurance plan has expired. In many cases, the waiting period is 120 days after the onset of the disabling condition, but it can vary between plans.
Deadlines for filing an LTD Claim
As soon as you become aware that your illness or injury will prevent you from doing your job and you want to claim LTD benefits, notify your LTD provider of your disability. Your LTD insurance contract specifies a deadline for notifying your insurer of your disability (30 days, for some plans) and also, for submitting a completed application including medical evidence of your disability. Some insurance providers for LTD coverage require claimants to submit their completed application for LTD benefits within a specified time before the ‘waiting period’ has expired which is, in some cases, three months before the date they are eligible to receive benefits (or, 3 months before the 120-day deadline). It’s a good idea to check your policy details and/or contact your LTD insurance provider to find out about the specific legal timelines for claiming LTD benefits. If you miss the contractual dates, you risk having your LTD claim denied.
Long-term disability insurance providers must assess, within the first two years, if a claimant is disabled with respect to their own occupation, and must be able to assess within a further two years, whether the claimant is totally unable to engage in any occupation for which they are reasonably qualified. One reason why waiting too long to claim long-term disability benefits can result in a denial of benefits, is that the insurer may be at a strong disadvantage (or ‘prejudiced’) when too much time has past, as it is increasingly difficult for the insurer to conduct assessments for the relevant period.
This is what occurred in a 2016 case, Ortiz v. Great-West Life Insurance, where a man was injured in a slip and fall accident and stopped working as a result of his injuries, but did not submit a Notice of Claim for LTD benefits until more than three years later. In this case, the plaintiff also named the wrong group insurer in his claim, which meant that the actual insurer-at-risk at the time of his accident, Manulife, did not receive notice of his claim until about five years from his date of injury. The judge dismissed the plaintiff’s motion to add Manulife to his claim after Great-West Life denied him LTD benefits on a number of grounds; but the key reasons were that both the notice period and limitation period to sue Manulife had passed and the plaintiff failed to practice reasonable and due diligence to discover the correct insurer.
In another recent case, Dube v. RBC Life Insurance Company (2015), the court came to a different decision – in this case, the appeal court upheld a motion judge’s decision that a man’s late claim for LTD benefits may proceed, despite the fact that both notice and proof of his claim were given well past the dates specified in the LTD plan. Under his policy with RBC, the plaintiff was required to give notice of his claim within 30 days of becoming disabled (or, the date of his accident) and submit proof of his claim within 1 year and 90 days; but the plaintiff did not give notice and proof until 22 months and 37 months, respectively, after he was injured in a car accident. RBC then denied his claim for being too late.
In Dube, the judges considered three criteria in their decision that the claimant’s late claim for LTD benefits will be allowed. The first criterion was whether the claimant’s conduct was ‘not unreasonable’, and on this issue, it was noted that the claimant’s employer had initially told him (incorrectly) that he did not have LTD benefit coverage and this created uncertainty and confusion. Also, the employer took one year to provide the claimant with an LTD application after he gave notice of his claim, and the claimant complied with numerous requests to submit medical information. In consideration of both these facts, the judge found that the plaintiff’s conduct was reasonable. The second criterion for accepting the late claim was whether the insurer would suffer prejudice due to the breach, and on this question, the judge decided that RBC would suffer only minimal or no prejudice. The third criterion considered “the disparity between the value of the property forfeited and the damage caused by the breach”, and the judge found that there was a significant disparity for the claimant because the claimant was 43 years old at the time of the accident and could conceivably receive long-term disability benefits until the age of 65.
How do you know you are eligible for LTD benefits?
In order to be eligible for LTD benefits within the first two years of becoming ill or injured, you must be able to show that your condition renders you unable to perform the duties of your current job. If your disability continues beyond two years, you are eligible for LTD benefits if you can show evidence that you are unable to perform any type of work for which you are reasonably qualified, given your education, training or experience.
LTD benefits application
When you complete an application for LTD, you will be required to submit detailed medical evidence, including your attending physicians’ statements that support your claim for disability benefits. Your insurer will require your physician(s) to complete a questionnaire which commonly includes information about your medical history, symptoms, a diagnosis, ongoing treatments, hospitalization, medical tests, functional abilities and a prognosis for recovery.
A representative or case manager for your LTD insurance provider will assess the completed application and medical evidence to determine whether your level of function meets the demands of your current job, to decide whether you meet the required definition of disability. Be aware that the insurer will also require a report from your work supervisor outlining the required duties of your current job.
A wide variety of conditions may prevent someone from performing their job or from performing any gainful employment, and symptoms may be physical, psychological or/or mental. Your long-term disability application will require evidence that you are receiving ongoing care and treatment that is deemed appropriate for your given disability. After your application is approved, you are also generally required to inform your LTD provider if there are any changes in your medical condition.
How long can I receive LTD benefits?
If you suffer from a prolonged injury or illness, and have provided medical evidence to support your claim, you are generally eligible to receive LTD payments until age 65, or the retirement date that was specified in an employer-provided plan.
If your claim is not approved until past the date on which you were eligible to receive LTD payments, your insurer should provide you with past-due payments from the date your eligibility for LTD began.
Denied LTD claim
If your claim for LTD benefits is denied, you should be given a specific reason. Insurers often have an internal appeal process; however, it is difficult to alter the insurer’s original position using the internal appeal process. Also, if the internal appeal process drags out a claimant may miss the deadline for filing a civil action. Therefore, we recommend retaining a lawyer immediately after your claim is denied so the court action against the LTD insurer can be commenced quickly.
Under any circumstances where your claim for owed long-term disability benefits was denied or your benefits were terminated, you are advised to seek the assistance of a skilled LTD claims lawyer at Kotak Personal Injury Law.
Disclaimer: This article is intended to supply general information to the public. We make every effort to ensure the accuracy of this information. However, as laws change quickly, the reader should always ensure the accuracy and applicability of such information with respect to their particular case. The information contained in this article cannot replace a thorough and complete review of the reader’s situation by competent legal counsel who has had an opportunity to review all of the facts.
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