When an insurance company denies or terminates a disability benefits claim, the person on the receiving end usually assumes that’s the final word, says Toronto disability lawyer Nainesh Kotak.
What many claimants don’t know is that disability insurers routinely cut off or deny legitimate claims for a variety of reasons, but that doesn’t mean you can’t challenge their decision, he says.
Claimants have a legal right to contest the disability insurer’s decision if they believe they made a mistake. Kotak says that challenging a denial on your own isn’t easy: Insurance policies are complex and filled with legalese, making it difficult for the average person.
“To effectively challenge a denial, you need evidence showing that the reason for the denial isn’t valid or that there’s information that hasn’t been considered in the assessment of the claim,” he says. “It’s always helpful for claimants to consult a disability lawyer who has a deep understanding of how the process works as well as a successful track record of resolving claims. Because we handle disability claims every day, we know how to deal with them effectively.”
Following are four common roadblocks claimants face dealing with disability insurance companies and the strategies Kotak Law leverages to navigate them successfully:
Roadblock #1: Denials based on pre-existing condition
Insurance policies often contain a pre-existing condition clause that disqualifies the applicant from receiving benefits if the coverage was in effect for less than a year before the disability arose.
“The insurance company investigates the 90-day period before the policy took effect to determine if you have been treated for or taken any medication directly or indirectly related to the condition associated with the claim,” Kotak explains.
“Let’s say you file a claim related to anxiety, but the insurance company’s investigation reveals you were previously treated for depression. Because they commonly lump mental health ailments like depression and anxiety together, they deny your claim based on a pre-existing condition.”
How a disability lawyer helps: Kotak says it’s not uncommon for insurance companies to misquote the provisions in contract clauses, but most people wouldn’t recognize that or know to challenge it.
“Claimants often give up at this point because they think they’re out of options. Your best chance of resolving the claim is by having an experienced disability lawyer review the policy in detail and confirm that the clause they’re relying on to deny the claim has been properly applied.
“We look at the person’s medical records and the specific ailments they were treated for and the associated timeline. If the condition they received treatment for is different or if they didn’t seek treatment in the 90-day period before the policy came into effect, we can challenge the denial,” he says.
Roadblock #2: Case managers with a hard-line attitude
Every claim file is assigned to a disability insurance case manager who reviews it and determines eligibility for benefits. Kotak says case managers often treat legitimate claims with suspicion, and once they make a decision, it’s difficult to change their position even when new information is offered.
“Clients frequently tell us their case managers don’t believe them and make them jump through hoops to supply more and more information for their claim. For some, the constant phone calls and emails are so stressful and triggering that their mental health declines even more.”
Case managers frequently take a “tunnel vision” approach in terms of the information they request from treatment professionals. Often, they ask leading questions designed to support their position, Kotak says.
“For example, instead of asking the doctor if the claimant’s ongoing symptoms prevent them from going back to work, they ask the physician for a return-to-work plan,” he says. “The distinction is important because the latter assumes the claimant is capable of returning to work.”
How a disability lawyer helps: When you hire a disability lawyer, you no longer have to deal with the insurance company, which is a huge relief for many people, Kotak says.
“When we issue a lawsuit for a denied claim, the case goes to the insurance company’s lawyer and a senior litigation specialist who looks at the case in a much different light than the case manager does. Once a legal claim is filed, insurance companies have to consider the cost of fighting it and possibly losing in court. Often, settling is the best option for everyone.”
Roadblock #3: Biased medical reports
Insurance companies retain independent medical examiners (IMEs) who frequently decide that claimants are able to work despite the fact that they have never met or examined them, Kotak says.
“In many cases, these medical consultants haven’t even received the complete record of medical evidence from all the treating professionals, so their determination is based on limited and incomplete information,” he says.
How a disability lawyer helps: Kotak says lawyers who frequently handle disability insurance cases know that the best way to counter a biased IME opinion is by providing solid evidence from medical experts, including the claimant’s treating professionals as well as a qualified independent medical professional.
What’s important, he says, is that the evidence provided by medical experts is based on the insurance company’s definition of “disability.”
“We ask questions that are applicable to the policy such as, ‘Is the person able to perform the essential duties of their job? Are they able to perform any gainful employment by way of their training, education and experience?’
Roadblock #4: Insufficient medical evidence
Disability claims are often denied on the basis of insufficient medical evidence, which means the insurance company isn’t satisfied that the applicant has provided proof they can’t work. Kotak says disability insurers typically invite claimants to provide additional medical reports, but that’s often a catch-22.
“No matter what information they provide, they’re repeatedly told the same thing: insufficient medical evidence, and you’re welcome to provide more information from your doctor at your own cost. This is a major obstacle that’s unlikely to be overcome without the help of a lawyer.”
How a disability lawyer helps: A lawyer helps you gather medical evidence to demonstrate that you meet the test of disability as laid out in the policy.
“Claimants are floundering on their own when everything they say or give to the insurance company is insufficient because what’s being provided doesn’t speak directly to the policy definition of disability,” Kotak says.
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 (Toll Free for all of Canada), or (416) 816-1500 (Local Number for Ontario Residents), (403) 319-0071, (587) 414-1010 (Local Numbers for Alberta Residents). Our consultation is free, and we don’t get paid until you do. We represent disabled people throughout Ontario and Alberta, 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, Keswick, Kingston, Ottawa, Banff, Brooks, Calgary, Edmonton, Fort McMurray, Grande Prairie, Jasper, Lake Louise, Lethbridge, Medicine Hat, Red Deer, Saint Albert and other locations.
