How to Appeal a Denied Disability Claim

A 2012 survey revealed that only 49% of the Canadians with disability were employed. For individuals living with disability, finding an employment opportunity is difficult, partly because of the stigma associated with different forms of disability and the presumed inability to perform some duties. The survey was a shocking revelation that individuals living with disabilities often face many challenges trying to get a job or making ends meet.

Luckily, disability insurance exists to protect you if you eventually suffer a disabling health condition or injuries. With this insurance cover, you can get regular disability benefits payments when you suffer injuries or a health condition that renders you unable to work for an extended period or permanently.

Long-Term Disability Claim Denial

An LTD insurance policy is intended to provide financial support when you can no longer work due to a disabling condition, which may not always be the case. It is common for some insurance companies to deny even legitimate claims.

A claim denial can be confusing, shocking, and terrifying. Claimants are left to wonder how they will continue to support themselves and their loved ones when they can no longer get meaningful employment or perform a profitable activity. However, you should not lose hope after your application for long-term disability benefits is denied.

Contact a knowledgeable long-term disability lawyer to help review your case and know your legal options. Insurance companies may not have your best interests at heart, but your lawyer has. This is your best chance to appeal a denied claim in Ontario.

Reasons for a Disability Claim Denial

When long-term disability claims are denied, some claimants do not challenge the insurer’s decision partly because they feel intimidated by the insurance provider. Indeed, it is tough between an insurance company that understands everything about disability claims and disability claimants with no experience in filing disability claims. Here are some of the reasons LTD claims may be denied in Ontario.

Inadequate Documentation or Medical Evidence

Most insurance companies deny LTD claims by alleging that the claimants failed to provide sufficient medical evidence and documentation to prove their disability. That means your insurer’s interpretation of the facts outlined in your medical documentation is not in line with your interpretation.

The claim denial letter most insurers issue is often an intimidation tactic to discourage you from moving forward with your claim. An experienced disability lawyer will review your medical documentation, consult medical specialists, and help you provide detailed medical evidence that an insurer may find hard to deny.

An insurer may argue you do not have a Long-Term Disability

In Ontario, a long-term disability means an injury or health condition that renders you incapable of performing the key duties of your occupation or any occupation for which you may be suited by experience, education, or training. However, your insurer may want you to believe that a disability refers to a catastrophic illness or injury. Yet, that is not always the case.

An insurance company may also deny your disability claim if you are residually or partially disabled. This is particularly true if you can still handle modified tasks or work part-time. However, even with a residual or partial disability, you may be entitled to disability benefits, only that your benefits payments are likely to be lesser than what you would get if you had suffered a total disability. Here are other reasons for LTD claim denial in Ontario.

• You have not been assessed by a doctor approved by your insurance provider
• You have exceeded the acceptable period for filing a disability claim
• Your benefits application had key misinterpretations, or you failed to mention a pre-existing medical condition
• The insurance provider has surveillance information that contradicts your LTD claim
• Your employer failed to provide the required documentation
• Your physician or doctor failed to document your medical condition or injury appropriately

Most disability insurance policies require that after getting disability benefits payments for two years, your condition must be reassessed. It should be evident that you cannot perform essential duties of any occupation that you may be qualified for to continue getting your disability benefits.

This requirement is different from the terms when you were applying for LTD benefits for the first time. During your first application, you needed to prove that your injury or medical condition prevented you from performing the key duties of your occupation.

After two years, you will need to prove that your condition prevents you from performing essential duties of any occupation for which you are suited or qualified through education, experience, or training.

What to do if your LTD Claim is denied

Whether you are denied CPP disability benefits or coverage under a private disability insurance policy, do not lose hope. Even when your insurer provides various reasons for denying your claim, you can still challenge the insurance company’s decision successfully. Here are your legal options after a claim denial.

Request for a Written Claim Denial Letter

If your insurer denied your LTD benefits, you should get a detailed written explanation. A claim denial letter from the insurer will highlight the reasons for the denied LTD claim. The letter must state the period you can submit another claim application, particularly if you have acquired more supporting medical information. In addition, the claim denial letter must outline the claim appeal process.

Usually, your insurance provider will call and explain the claim denial over the phone. Before the end of that call, insist on getting the claim denial letter in writing. When you get it, work with a knowledgeable disability lawyer to review your CPP disability application, identify all errors that may have led to claim denial, and acquire all relevant supporting documents. This will make the claim appeals process or legal claim easier.

Gather Supporting Documents

Sometimes, an insurer may deny your Canada pension plan disability claim based on insufficient documentation. At the time you are filing your disability claim, your insurance provider will require a carefully filled physician statement. It is wise to get an experienced lawyer to double-check this statement to ensure it is professionally filled before sending an appeal letter to your insurer’s claim appeal division.

An experienced lawyer can help you draft a strong appeal letter to ensure your first appeal is successful. If your lawyer has uncovered new evidence that could support your claim, it is recommended that you submit it to the insurer. Remember, omissions or errors can derail your appeal even after submitting additional information to your insurer.

File a Legal Claim

In most cases, appealing for a disability claim denial does not work after the initial denial. Therefore, it is better to pursue a legal claim against your insurance provider. When you submit an appeal for denied disability benefits, an appeal division of the same insurance company that initially denied your claim will handle the appeal.

Thus, your insurer could use the appeals process to stall out the 2-year window you have to file a legal claim. Once this period lapses, you lose your chance of filing a legal claim and obtaining the compensation you deserve.

Once you submit your LTD claim, your insurer can choose to award the disability benefits you seek or spend money fighting your claim in a federal court. This is why you should consult a skilled lawyer to ensure your initial disability benefits application is error-free. The lawyer can also help you file a legal claim against your insurance provider if your claim is denied.

At Grillo Law, we handle LTD claims in Ontario and across the country regularly. For many years, we have helped many clients to secure disability benefits. Our experienced and knowledgeable lawyers give disability applicants the advice and legal support they need to secure the compensation they are entitled to.

FAQs

How do I maximize my chances of success when filing an LTD claim?

Seek medical treatment from a specialist who can provide the right prognosis and effective treatment. Discuss your job responsibilities with your doctor to determine how your injury or medical condition may affect your ability to perform the essential duties of your employment. Be sure to hire an experienced lawyer.

Why did my insurance provider deny my benefits application?

Your insurance provider may deny your CPP disability claim or disability benefits applications under your private policy for many reasons. These reasons will be outlined in your claim denial letter.