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Long Term Disability Denied

Long-Term Disability Insurance Claim Denied? - Here is What You Should Do

July 23, 2019 - in

People who are unable to work due to injury or illness face double jeopardy in that they have to suffer through the pain and discomfort of their medical condition, while also worrying about how they are going to pay the bills and support their families. And while long-term disability insurance is designed to alleviate the latter aspect of this double jeopardy, countless Ontario residents face the added burden every year of having their claims for long-term disability denied.

If you are facing a long-term disability denial, there are numerous tactics you should consider to counter the denial and secure a successful resolution of your claim. First off, though, be aware that there are important timelines in the appeals process and in the initiation of legal action to counter the denial. Keeping track of and meeting appeals deadlines and related time frames is imperative to ensuring that the insurance company does not run out the clock on your legal right to appeal or seek legal redress through the courts.

Second, seek professional advice from an experienced disability denial lawyer. Long-term disability policies are highly complex and written with legalese and complicated provisions that are typically unclear to the average person. Not only can disability lawyers help you navigate through the legal language, appeals process, and any possible legal action, but will ensure that you adhere to all necessary deadlines. Additionally, the services of a skilled disability lawyer lets the insurance company know that you are serious about fighting for your rightful benefits.

Long-Term Disability, and Denial Thereof, is Subjective

Workers covered under an employee benefits plan or with their own private long-term disability insurance plans can typically put in a claim for benefits after their short-term disability payment period has ended. Under such plans, workers are supposed to be eligible for disability compensation based on a percentage of their regular salary and payable for a specific time period laid out in the policy or until the worker is well enough to return to work.

However, the decision on whether to allow or deny benefits is highly subjective, based on the wording of the policy and the company’s interpretation of some key terms. For example, the term “total disability” tends to be a key component in the resolution of many long-term disability claims, with the extent of “total” within the term often being subject to the whims of insurance company interpretation. An experienced disability denial lawyer is skilled in the art of ensuring that any such subjective interpretations of total disability are reasonable according to the dictates of insurance law and legal precedents.      

To prove eligibility, workers have to prove that the medical condition makes working in their current occupation impossible whether due to physical, mental, emotional, or social reasons. Under the terms of most disability insurance contracts, benefits are initially applied based on the inability to perform tasks conducted within the scope of their “own occupation.” However, after a two-year timeframe most policies dictate that claimants must prove that they are unable to perform tasks for any job in which they may be suited based on experience, training, and education. This “own occupation” timeframe clause allow the companies to push workers into seeking other work that they may be able to perform in spite of the disabling condition, and is used to justify many long-term disability denials.

As with the “total disability,” though, what constitutes the ability needed to take on “any occupation,” is subject to interpretation, with the insurance company’s interpretation often at odds with the legal interpretation and precedents.                   

The Insurance Companies Consider This “Strictly Business”

While long-term disability denial may feel like a slap in the face - the adding of insult to injury - to those turned down, for the insurance company it is strictly business. Naturally, an insurance company needs to protect its business model by weeding out false claims, but most of them go beyond looking for fraud and typically seek out any justification for denying a disability claim. After all, the more money an insurance company has to pay out in disability claims, the less profit the company, and its shareholders, earn. Thus, insurance companies have built up extensive experience in how to negate disability claims and rely on crafty disability lawyers to help them do it.

Reasons Given for Denying Disability Insurance Claim

Insurance companies seem to have as many reasons for denying disability insurance claims as there are conditions that might lead to a disability. Disabling conditions are generally detailed in your distinct policy, which will dictate what conditions are eligible and which ones may not be. But even if your specific medical condition seems to make you eligible for benefits, the insurance company may find you ineligible and deny benefits. Among the many reasons an insurance company may use to deny your long-term disability claims are:

  • Your condition does not prevent you from doing certain parts of your job.
  • Your condition may prevent you from doing “your job,” but does not prevent you from doing “other jobs.”
  • Details of your medical condition are deemed insufficient to prove disability.
  • Conflicting information between your doctor’s medical reports and independent medical reports conducted on behalf of the insurance company.
  • Failing to complete the disability application correctly.
  • Failing to submit the application on time.
  • Incorrect or missing information in the application.
  • Claims that there is misleading information in the application.

If Denied Keep an Eye on the Clock

No matter what reason is given for long-term disability denial, know that this initial denial usually marks the start of what’s known as a “limitation period.” The length and timing of limitation periods can vary depending upon the small print in your policy, but typically means that you have two years from the date of denial to sue the company for denying your disability claim. Upon expiration of the limitation period deadline, your ability to sue will be denied by the courts. The company’s appeals process also typically includes deadlines for challenging the denial. 

Do Not Let the Appeals Process Run Out the Clock

With a deadline in place that will ultimately preclude your ability to mount a legal challenge to a disability denial, it is in the insurance company’s best interests to stall any efforts made on your part to resolve the dispute. Thus, do not be surprised if the insurance company takes its time in responding to your phone calls or any requests for information regarding the denial.

The appeals process as detailed in your policy does provide an avenue for getting the insurance company to reconsider the denial. However, the burden of proving that the denial was wrong is on you, and the appeals process itself can take significant time as it runs down the limitation period clock.

Most workers find that if they lose the first appeal, they generally lose subsequent appeals as well. Meanwhile, the insurance company is running down the limitation period while also boosting its paperwork record that lays out its justification for the denial. With more details about your claim offered in the scope of the appeals, some insurance companies use the appeals process timeframe to mount a closer investigation of your claims. This can include efforts to collect video surveillance evidence on workers with mobility claims, and/or examination of activities and behaviors that may be posted on Facebook or other social media.                

Engage Disability Lawyers for your Appeals

Many workers tend to be reluctant to seek legal advice until after they have exhausted their long-term disability appeals. But the sooner you engage a disability denial lawyer to help you with your long-term disability denial, the more effective the potential defense of your claim. A disability denial lawyer can tailor an effective appeal appropriate for both the unique disability claim and the dictates of the insurance contract (policy). Because the appeal becomes part of the claims record, a disability denial lawyer can also ensure that your appeal cannot be used to compromise any possible future legal action, should the dispute come to that.

Other Factors to Consider When Challenging a Long-Term Disability Denial

Whether you decide to go it alone during the appeals process or engage the services of a skilled disability denial lawyer, there are numerous other factors you need to keep in mind while mounting a successful defense of your claim for long-term disability benefits. To help ensure the successful resolution of your disability claim, make sure you do the following:

  • Keep all written records pertaining to your medical condition, as well as any written correspondence between you and the insurance company.
  • Take notes and try to detail in writing all interactions you have relating to your disability with your doctor and/or other medical professionals.
  • Make sure you get the names of any insurance representatives you talk to and try to detail in writing any conversations you have with them.
  • Try to keep track of how your condition affects you, by writing down details and timing of how pain and other symptom impact your daily life.
  • Do not sign anything from the insurance company or any of there representatives unless you are positive that you know what you are signing.
  • If the insurance company requests that you undergo testing by independent medical professionals at their expense, make sure that you collect as much information possible about the testing and its administrators. If possible, take notes about any procedures/tests administered and request the names of all involved. 
  • Remember that the disability denial initiates deadlines that may preclude your future ability to continue challenging the denial, so be proactive in mounting a timely challenge. 

Make Sure That You Also Take Care of Your Personal Well Being

For your personal well-being during what will likely be trying times, make sure you account for these factors: 

  • First and foremost, take care of your health. If you are not satisfied with the medical attention and/or treatment you are receiving for your disabling condition, let your medical professionals know. If medications or treatment regimens are not working, advocate for yourself and seek out further medical attention, whether by asking to try other medications or by seeking referrals to other medical specialists.
  • Know that mounting a successful challenge to disability denial often takes significant time, and thus will likely necessitate the need to secure other funding for day-to-day living. Thus, seek support from government agencies that provide assistance to Canadians who cannot work or generate income. You can seek such support from Ontario Works (OW), Ontario Disability Support (ODSP), and Canada Pension Plan Disability Benefits (CPP Disability), without worrying about any impacts this may have on your credit rating. 
  • Do not take the long-term disability denial personally and allow the potential ramifications of the denial to dictate your response or how you live your life.    

Contact Lerners Lawyers to Challenge Your Long-Term Disability Denial

With 90 years of professional experience in the greater Toronto area, Lerners LLP has a a stellar record in helping clients successfully challenge long-term disability denials. Lerners LLP also has the respect of insurance companies that know that the lawyers at Lerners do not take on clients with dubious or potentially frivolous claims. In fact, some disability denials have been re-examined and reversed upon Lerner’s initial communications regarding the denial.

Absent such quick resolution, Lerners LLP works diligently to secure a successful resolution of its client’s claims. From the appeals process to the actual trial, if needed, Lerners LLP is committed to securing fair and just compensation their client’s long-term disability. Lerners’ disability denial practice area is headed up by Steven Polak, who specializes specifically on injury and disability claims. A member of the Ontario Trial Lawyers Association Long-Term Disability Litigation section, Steven has intimate knowledge of all aspects of disability denial law, having previously worked on behalf of insurance companies. Steven has been with Lerners LLP since 2002.      

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