Group disability insurance is designed to give employees peace of mind if an illness or injury prevents them from working. Group insurance plans for short- and long-term disability provide financial protection by way of disability benefits, allowing someone to pay their rent or mortgage and other bills during their recovery.
Too often, disability insurance claimants are required to jump through excessive hoops to prove they are, in fact, unable to work. The ordeal leaves them frustrated, and without the financial lifeline, they depend on to live their lives. The impact is often worse for those already dealing with mental health issues.
Recently, our firm represented a 51-year-old woman, a longstanding employee of a major financial institution in Ontario, in a lawsuit filed against her employer and her disability insurance company. In this post, I’ll chronicle her journey and the steps we took to successfully resolve her claim.
How it started
Jane (not her real name) has a history of anxiety that presented when she was in her 20s. She successfully managed the condition for many years, though she admitted it was always lurking in the back of her mind.
A couple of years ago, as work became increasingly stressful, Jane’s anxiety levels soared to the point where she had frequent panic attacks in the morning before going to work.
Following a client complaint about her performance, Jane’s supervisor met with her and delivered a reprimand, causing her to have a panic attack on the spot. The next day, she went to her doctor and described her emotional state: she was afraid, anxious, had frequent headaches and ongoing panic attacks that compromised her breathing and caused a host of other unpleasant symptoms.
Medical research shows that panic attacks come on suddenly and usually involve intense feelings of fear coupled with symptoms such as chest pain, fast breathing, nausea and excessive sweating. While a stressful life event can bring them on, they frequently appear to be triggered by nothing at all, according to the Canadian Mental Health Association.
Jane’s doctor diagnosed her as having panic attacks, major depression and severe anxiety. The physician put together a treatment plan and advised her to take time off work until her symptoms improved.
Jane applied for short-term disability (STD) benefits through her group disability insurer. Under the plan, benefits are paid by the employer but administered by the insurance company. That means that the insurer oversees decisions relating to her claim, and the employer is responsible for payment. Under the terms of the policy, Jane was eligible to receive up to six months of benefits before transitioning to long-term disability, if necessary.
Jane’s claim was approved, but her disability insurer terminated it after just five months based on a report from their Independent Medical Examiner, claiming there was no objective evidence to prove she couldn’t work. While her STD claim was active, Jane endured constant haranguing by the insurer. They called her three to four times a week in addition to sending her frequent emails asking for accounts of the treatments she was receiving, what she was doing to get better, and why she hadn’t yet seen a psychiatrist.
STD benefits cut off
Anyone who has struggled with mental health issues knows how challenging it is to get an appointment with a psychiatrist in Ontario.
In a Globe and Mail report several years ago, family doctors described psychiatrists as the most difficult specialists to access.
Meanwhile, Jane was receiving treatment from a psychologist, in addition to regular appointments with her family physician. But the insurance company’s relentless demands were taking a toll on her mental health and exacerbating her symptoms. At this point, she was fearful of answering the phone. She avoided checking email as there would almost certainly be one from the disability insurer’s case manager requesting additional information from her, again.
Several weeks before her STD claim ended, Jane’s disability insurance company got an opinion from a physician they hired, but who never met Jane, claiming there was no objective evidence to indicate she could not work. That despite evidence supplied by her own doctor, who she regularly saw, that she wasn’t ready to return to work.
Appealing the disability insurer’s decision
If your insurance company denies your claim, you have two options:
1. Insurer’s Internal Appeal Process
Most disability insurers offer an appeal process for denied claims, but they can drag on for months, and it’s rare for insurance companies to change their position. Throughout the appeal, the insurance company often requests additional documentation to support the claim, placing more of a burden on fraught claimants who need to pay out of pocket for the additional expenses.
2. File a lawsuit
Hiring a reputable disability lawyer offers you the best chance of resolving your claim. As a law firm focusing on fighting for the rights of those whose disability claims have been denied or terminated, we understand how to navigate the insurance companies’ red tape.
An experienced lawyer can guide you through the process, ensuring the relevant forms and documentation are taken care of and help you negotiate a fair settlement. It’s important to note there’s a limited time to sue the insurance company; claimants have two years from the date their claim is denied to file a lawsuit.
Internal appeal unsuccessful
Unsuccessfully, Jane appealed through the disability insurer’s internal process and subsequently hired us to dispute the denial.
It was clear she was suffering from anxiety, depression and panic attacks, as indicated by her doctor, and we were confident she had a strong case. During conversations with the insurance company, we asked about filing a claim for LTD benefits, but they said she was ineligible for long-term disability benefits because she didn’t complete her full STD entitlement.
We gathered records and opinions from her family doctor, psychologist and an independent psychologist, who provided a medical opinion on her functional ability. All three determined she was unable to perform her job or any gainful employment due to her medical condition. But the insurance company didn’t budge.
We filed two lawsuits on Jane’s behalf: one against the employer (payor of the STD) and the other against the disability insurer for inducing the breach of contract of her short-term disability policy and for failure to pay long-term disability benefits.
How we resolved Jane’s case
In Jane’s case, we requested an early mediation and the insurer agreed. We selected a mediator who is very experienced in mediating disability cases and with whom we have had great success in terms of getting significant compensation for our clients.
Ahead of mediation day, we prepared Jane for what to expect and how to effectively communicate the impact her anxiety, depression and panic attacks had on her day-to-day functional abilities.
We prepared a detailed mediation brief, setting out the issues and demonstrating why, according to the terms of her policy’s definition of total disability, she qualities for benefits.
On mediation day, we delivered a strong opening statement. Jane spoke tearfully about how her quality of life deteriorated when her benefits were denied. The financial fallout led to a strain in her marriage and interfered with her ability to be present for her children and deal with their day-to-day needs.
After a long day, the case was resolved, and we were successful in obtaining a fair settlement for our client. Jane received a lump-sum payment from the employer as well as the insurance company.
Helping clients like Jane is the reason we practice disability law. Her story illustrates why claimants shouldn’t blindly accept their disability insurer’s decision to deny or cut off benefits. They have a right to dispute the insurance company’s decision.
If your disability insurance claim has been denied or cut off and you’re considering hiring a lawyer, our blog post has helpful tips and questions you should 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.
Call your trusted long-term disability lawyers at 1-888-GOKOTAK or (416) 816-1500. Our consultation is free, and we don’t get paid until you do. We represent disabled people throughout Ontario 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, Fort Erie, Keswick, Kingston, Ottawa, Barrie, Timmins and other locations.