Learning that your long term disability claim has been denied can be discouraging and add to the stress already caused by the disability. The immediate temptation may be to use the insurer's appeal process to try to earn your disability settlement.
That would be a mistake.
An insurance companies' internal appeal process can take years to come to a resolution. Not only is this frustrating, but also means too much time may have passed for you to sue your insurer for disability benefits.
That's why it is vital to consult a disability lawyer to assert your rights and win your disability benefits.
Toronto Disability Cases In the News
Qualifying for Long Term Disability Benefits in Toronto
Long-term disability benefits are intended to provide income replacement for anyone who has a medical condition that prevents them from working for an extended period. Unlike eligibility for workplace insurance benefits, the given medical condition need not have originated in the workplace; it may have resulted from any situation, including an accident, serious illness, hereditary condition or injury. Whether you belong to an individual, group (such as an employer plan) or special purpose disability insurance plan, you have the right to expect this coverage to become available when you suffer from a long-term illness, medical condition or injury. You are not alone; about one out of three Canadians experience a long-term disability of at least 90 days during their working years.
We know how vital disability income is for people who are no longer able to work due to illness or injury. The inability to earn an income can rapidly run through our savings, RRSPs and even our home equity. Most policies pay the majority of the income you were receiving in your regular job prior to becoming disabled, generally subject to a monthly maximum amount, for up to two years. After two years, in order to continue to be eligible for long-term disability benefits, a person must prove themselves unable to perform any work for which they are reasonably qualified.
You should qualify for long-term disability benefits if you are not able to complete a substantial portion of the tasks required in your normal occupation. However, some policies state that you must prove that you are unable to perform any job for which you are qualified, based on your education and so on, in order to be eligible for these benefits. For this reason, it is important to check all the details of any insurance policy when you apply, to ensure that you are entitled to the benefits and coverage you hope to receive in the event of injury or illness.
Making a Claim For Benefits
The most important steps when you suffer from a disabling illness or injury are:
Seek immediate and appropriate medical attention for your condition
Follow up on all recommended treatments
Inform your insurer and/or employer as soon as possible of your condition
Meet the required timelines for making a claim
Provide all the substantiating documentation required on the Long-Term Disability Application
Be honest in the information given to your insurance provider
Be careful of what you publish on social media sites
As soon as you become aware that your condition or injury may require long-term disability benefits, do not delay in notifying your insurer and/or employer of your claim. As with any insurance claim, there are deadlines for filing and your policy provider will require you to complete a claim application and provide medical evidence for your condition. An application for long-term disability coverage will generally request the following information:
Personal information, such as your age, dependants, and so on
A list of medical references and health care workers you consulted
Medical assessments and treatments
Details of your illness/injury, such as the timing, source of injury, when treatment was sought, and so on
Other sources of income, including pertinent insurance policies
Aspects of your job that you are no longer able to perform
Denial of long term disability benefits
Even after undergoing the somewhat complicated and lengthy process of applying for long-term disability benefits, individuals with a legitimate need are sometimes denied coverage or have their benefits terminated while still unable to return to work. Under any circumstances in which your benefits are denied or prematurely terminated, consult with a personal injury lawyer to help resolve the issue and act as your representative against the insurer.
Sometimes denial of coverage can be resolved by obtaining required medical documentation or evidence, or your employer may have failed to provide all the necessary information for your application. Insurance providers also sometimes dispute claims because the claimant did not reveal a pre-existing condition, submitted inaccurate information or failed to follow up on medical treatments prescribed by their health care professional(s). Another reason why a claim may be disputed is your insurer argues that your injury or condition is not serious enough to qualify as a total disability.
Many people don’t realize that what they say in social media may sometimes work against them when they make a claim for any type of injury/illness compensation. When you file a claim, the insurance company may research a number of sources to determine whether you were honest and complete in documenting the severity of your condition and how it affects your ability to function normally. Someone who publishes pictures of themselves participating in sports or writes comments about their physical activities and that they are feeling ‘fine’, on Facebook or another media site, may be surprised to learn that their insurer can use this information as proof that their condition was exaggerated.
Mental illness can be every bit as incapacitating as a physical condition, sometimes even more so. Individuals suffering from a mental condition such as depression or post-traumatic stress syndrome (PTSD) qualify to receive long-term disability benefits, but insurance providers sometimes make it more difficult for sufferers to receive their owed benefits simply because mental illness can be more difficult to substantiate. For this reason, anyone experiencing a mental condition that prohibits them from working is advised to seek help from an experienced lawyer who understands how to ‘work the system’ and obtain needed expert opinion and evidence to substantiate your claim.
After two years of receiving long-term disability payments, if you continue to be unable to be gainfully employed, additional medical assessments and evidence will be required to show that you are unable to perform any occupation for which you are reasonably qualified.
If you have provided all the required information on your claim application and negotiations with your insurance provider are unsuccessful in obtaining owed disability benefits, then your lawyer can file a lawsuit against your insurer. Often your claim can be resolved without having to try your case in court.
At Kotak Law, we understand the challenges to Canadians who are struggling with a long-term disability, both with respect to your physical recovery and rehabilitation, as well as the stress in dealing with a complex application process or the denial of your claim. Our goal is to alleviate the burden of having to negotiate with your insurance provider and also relieve some of your financial burden, as we do not require any payment until your claim is resolved.
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.
Kotak Personal Injury Law
607 Gerrard Street East, Suite 403 TorontoOntarioM4M 1Y2
Helping you from the very start Kotak Personal Injury Law is a Mississauga personal injury law firm handling wrongful death and injury cases including car accidents, slip and fall, dog bites, defective products as well as disability insurance, critical illness insurance, mortgage insurance and credit card insurance claims. Serving Peel Region, Halton Region and the Greater Toronto Area, including Mississauga, Brampton, Oakville, Burlington, Caledon and Halton Hills, Ontario