Received a STD or LTD Denial? Learn what to do

Jul 27, 2017 | Legal Article

Rachelle Mitri

Legal Advice

 

Your employer may wholly or partially fund, group disability benefits for you, as an employee. These benefits are meant to protect you in the event you suffer an illness or injury and are unable to work. This is a form of group insurance and is governed by an insurance policy. For this reason, the contract (insurance policy), is the key tool in determining your entitlements. Consult a licensed associate at Grillo Barristers to interpret the contract for you and argue for every last penny owed on your behalf.

What is the difference between a short term disability benefit and a long term disability benefits?

What to do if you have received a STD or LTD Denial
One of the most common questions we get at Grillo Barristers is the difference between a short term and long term benefit. Quite simply, a short term benefit provides interim relief and compensation for an individual who has been injured in an accident or is dealing with certain medical conditions or illnesses and is unable to continue on their normal course of employment or daily activities. There is often a “cooling period” involved, that provides an initial period of time immediately following the onset of an injury or illness, within which the insurer does not have to commence payment of a short term disability benefit. The duration of a short term disability benefit will vary, pursuant to your insurance policy. More often than not, said benefit lasts between 13 to 26 weeks, but may last up to 52 weeks. It usually compensates you for up to 40-60% of your prior gross income.

In order to apply for short term disability, the claimant must provide a physician’s statement corroborating the medical claim (for injury or illness), as well as prognosis and timeline of recovery. They would also need to provide a personal statement testifying why they are no longer able to continue in their job role, as well as an employer statement providing an outline of the job description, occupational duties, and the now reduced role that the employee is undergoing.

 Long term disability benefits on the other hand, provide additional coverage when your short term disability benefits have expired or run out, and where the claimant remains entitled to receipt of the benefit. Long term disability insurance can cover you in the event that you are left unable to work for an extended period of time, and generally replaces about 60 to 70% of your prior gross income, subject to certain maximums. The legal test for entitlement often changes and becomes much more strenuous when the claimant is unable to resume his/her employment for a period of over two years. Commonly, the standard changes from being unable to resume the tasks of one’s own employment, to being unable to perform the tasks of any employment beyond the two year mark. Once again, when in doubt, the insurance policy or benefits booklet should help clarify. The help of legal counsel is always advised when your disability insurer wrongfully terminates your disability benefit.

For more information, consult a legal professional who can assist you with the terms and conditions of your disability insurance coverage.

What happens if I am denied?

Unfortunately for victims, a vast majority of insurance claims for short term or long term disability benefits are denied. Insurance companies have a number of reasons why they may deny someone, but often case it will come down to administrative reasons (e.g.: such as error in application filing or insufficient information), the decision of the insurance adjuster (who may reduce or re-evaluate the extent of the claims), or other circumstantial reasons.

Being denied coverage by your insurer is extremely frustrating and many of our clients come to us afraid that they will be left behind. Fortunately, there are several options available to you and the experts at Grillo Barristers can help. First, many private insurance companies offer an internal appeals process for the claim to be reviewed. The details and procedure of this will be provided to you in writing on the form notifying you of the denial. While some people choose to undergo this appeals process themselves, it is highly recommended to seek legal opinion and assistance in this matter. The internal appeal process can be lengthy and arduous, and having the weight of a law firm behind the appeal or claim can make the difference between a successful claim and an unfortunate failure.

Furthermore, consider the options outside of the internal appeals process. The lawyers at Grillo Barristers have been dealing with private insurers for over 25 years and as a result have established working relationships with them. Having these legal resources at hand can be helpful in the negotiating process, where we will advocate for your rights and the full extent of the benefits you deserve. Finally, in some situations, it may be appropriate to engage in litigation against the insurance company, especially where (in our legal opinion) we feel that the insurer has acted in bad faith or contrary to the contractual agreement.

Each case is highly individual and specific, and we invite you to a free consultation where you may explore your legal avenues. Here at Grillo Barristers we have a dedicated and experienced team ready to serve your needs.