What to do if Disability Claim is denied?    

A medical condition or injury can affect your life in many ways. For some Canadians, returning to work may no longer be an option due to the nature of their illnesses or injuries. When this happens, your long-term disability insurance cover, like the Canada Pension Plan Disability benefits, may offer the financial support you need.

However, after paying your insurance premiums for years and you have a disabling health condition, your application for disability benefits may still be denied. What should you do in that situation? Remember, the outcome of your long-term disability claim will affect your finances, life, and future.

Therefore, when your insurance provider denies your application for long-term disability benefits, do not give up hope. You can take essential steps to appeal the insurer’s decision or file a legal claim to get the financial support you need to carry on with your life. You just need to contact an experienced lawyer to help you handle the claim denial appeals process or file a legal claim against your insurer.

Disability Insurance

In Canada, disability insurance can protect eligible individuals and their loved ones from the financial impact of a disabling health condition or injury, particularly when one can no longer return to work. It can replace between 60% and 80% of the income you were receiving before the onset of your disabling condition.

Indeed, disability insurance can replace your income up to a pre-determined amount and period if you are unable to perform the essential duties of your occupation (or any other occupation) temporarily or permanently. Remember, the definition of ‘disability’ may change from being unable to perform the essential responsibilities of your ‘own occupation’ to ‘any occupation’ after a certain period (often two years).

Most employers in Canada offer disability insurance to their employees. If you are self-employed, you can get a private disability insurance policy. This policy can cover you and some of your business expenses if you are unable to work. Therefore, it is crucial to consult an experienced lawyer when acquiring a long-term disability insurance policy. This will ensure you understand the terms of your policy and make an informed choice.

The Canada Pension Plan may be another source of disability benefits payments. This option is available to individuals who have contributed to it and can no longer perform the essential duties of their occupation or any occupation due to a disabling condition.

Appealing an LTD Claim Denial

Most LTD benefits applicants often give up after receiving a notice of claim denial (often a claim denial letter) from an insurance company. If your claim was rejected, do not give up. It is also not a good option to rush and reapply for the LTD benefits without the help of a skilled lawyer.

To pursue your claim or the appeal process in the right way, seek legal advice and support from an experienced lawyer. This is your chance to address the issues that led to the initial claim denial and increase your chances of getting fair compensation. Here are the steps you should follow to appeal denied disability benefits successfully.

Request a Reconsideration

Suppose your insurer denies your application for your CPP disability benefits. In that case, you will get a notification letter from Service Canada outlining the reasons for the claim denial. The letter should also highlight the specific steps that you should take to request a reconsideration of the insurer’s decision.

Your request for reconsideration of the claim denial is a crucial step in the appeal process. It will prompt a thorough review of your initial application by an individual not involved in the initial assessment of your benefits application.

When filing a request for reconsideration, you can also submit any new documentation or information that could strengthen your claim. The new information will be considered in the review. Therefore, you should work with your lawyer to gather detailed medical information that could support your claim before you initiate the appeal process.

All requests for reconsideration must be made through a letter. You must submit the request for reconsideration within 90 days from the date you are notified of your long-term claim denial. You can send your request for reconsideration through registered mail or any other option that allows tracking. This way, you will have proof of your letter if it gets lost.

Social Security Tribunal – General Division

If your request for reconsideration is denied, you can appeal to the Social Security Tribunal’s General Division. This is an important step in the appeals process for long-term disability (LTD) benefits. The Social Security Tribunal is an independent administrative tribunal that will review your case and determine your eligibility for LTD benefits. This tribunal operates impartially and this will ensure a fair assessment of your case.

How the SST Hears Appeals

The SST will decide the best method to hear your appeal. There are several options for conducting the hearing. These include:

• Telephone Conference: This option allows you to participate in the hearing from your home or another suitable location. It ensures you can present your case without the need to travel.
• In-Person: This option provides an opportunity for a face-to-face hearing and allows for direct interaction with the tribunal members.
• Video Conference: This hearing option combines the benefits of in-person and telephone conferences and offers a visual component, which can be crucial in certain cases.
• In Writing: Suitable if you prefer to submit detailed written arguments, and it allows you to provide comprehensive documentation without attending a hearing.

Work with an experienced long-term disability lawyer to ensure you adhere to all hearing requirements and avoid various mistakes that could derail your LTD claim appeal.

Preparing for the SST Hearing

Before the hearing date, you can submit any new documentation or information to support your appeal. This is a critical step in ensuring the success of your appeal. For instance, you can continue to receive medical treatment and collect any new medical information from your physician. This ongoing documentation can significantly strengthen your case.

Work closely with your lawyer to gather all necessary documents and information. An experienced lawyer will know what types of evidence are most compelling to the Social Security Tribunal. This might include:

• Medical Records: Detailed medical reports from your healthcare providers outlining your condition and its impact on your ability to work.
• Treatment Plans: Documentation showing your commitment to following medical advice and treatments.
• A Physician’s Statement: Your treatment providers’ written account of how your condition affects your daily life and ability to work.

One of the reasons your CPP disability benefits or LTD benefits under a private policy may be denied is insufficient medical evidence. Having a knowledgeable lawyer on your side can make all the difference during the medical evidence and documentation process.

Initiating the Appeal

To initiate an appeal with the SST’s General Division, you need to hire a disability lawyer immediately. The lawyer can help you submit a written letter of appeal or complete the ‘Notice of Appeal’ form. This must be done within 90 days of receiving the initial claim denial notification.

• Written Letter: Your letter should clearly state why you are appealing the decision. Include any new evidence or documentation that supports your case.
• Notice of Appeal Form: This form is available from the SST and can be filled out to initiate your appeal. Ensure all sections are completed accurately and thoroughly.

Submit your appeal through a reliable method such as registered mail or another tracked delivery service. This will ensure you have proof of submission, which is important if any issues arise regarding the receipt of your documents.

Social Security Tribunal – Appeal Division

Suppose you appealed your denied long-term disability benefits to SST’s General Division and got a denial. In this case, you have another avenue for appeal – the SST’s Appeal Division. This is the last appeal option and the most challenging – you don’t have the right to appeal; instead, you should seek and obtain ‘leave’ to submit an appeal. That means you need to first obtain permission to file an appeal.

The ‘leave’ or permission to appeal at the SST’s Appeal Division may be granted if the General Division fails to observe the natural justice principle. It may also be granted if the General Division erred in making the denial decision and (or) based its decision on an erroneous fact-finding or without considering the information/evidence presented.

If you satisfy any of the three conditions for leave to appeal to the SST’s Appeal Division, you may initiate the appeal process by writing an appeal letter. Alternatively, you can submit a request for leave to appeal to the Appeal Division.

Remember, you have only 90 days to submit an appeal letter or complete the application form for the appeal. You should also submit a copy of the General Division’s decision you intend to appeal and all other authorization forms.

An Experienced Lawyer can help

The entire process of appealing a long-term disability benefits denial can be time-consuming, challenging, and frustrating. Sure, you can read and understand this process, but it would be much easier to have an experienced lawyer handle your case. At Grillo Law, we will provide the legal representation and support you need to appeal your claim denial successfully.

Ignore the Appeal Process and File a Legal Claim

As mentioned previously, you can get long-term disability insurance coverage through the CPP, group insurance plans (offered by employers), privately purchased LTD insurance policies, and more. When you are faced with an illness or injury that renders you incapable of returning to work, there is a legal way of collecting your disability benefits from an insurance company.

Unfortunately, most insurance companies are always looking for various reasons to reject long-term disability claims. By failing to make disability benefits payments, an insurance company can increase its profits.

If an insurance company denies your long-term disability claim, do not lose hope. Consult an experienced disability lawyer to review your disability benefits application (claim) and help you understand your legal options. Remember, an insurance company may not prioritize your rights and best interests, but your lawyer will.

File a Legal Claim

Most long-term disability benefits applicants feel frustrated and discouraged when insurance companies reject their long-term disability claims. However, you have the right to question an insurance company’s decision to deny your disability benefits application. This is your chance to understand the specific circumstances that led to your claim denial.

An experienced disability lawyer can help you ask the right questions and determine if the insurance company has legally acceptable reasons to reject your claim. Here is what you should do if an insurance company rejects your LTD claim.

Request for the LTD Claim Denial Letter

When an insurance company denies your claim, it is essential to insist on receiving their decision in writing. A written claim denial letter is crucial for several reasons. First, it outlines the specific reasons for your long-term disability claim denial. This can help you understand the insurer’s rationale and identify any potential errors or misunderstandings.

The claim denial letter will also state the limitation period, typically two years, within which you can take legal action against the insurance company. Knowing this timeframe is critical to ensure you do not miss any important deadlines.

While some insurers may call to explain the reasons for claim denial, you should request a written denial letter at the end of such calls. This document is vital for your process to either appeal the insurer’s decision or pursue legal action against your insurer. Seek legal advice and support from experienced lawyers to navigate the legal claim process effectively and improve your chances of a successful outcome.

Obtain Relevant Supporting Documentation or Evidence

An insurance company may deny your long-term disability claim due to insufficient supporting medical information or inadequate documentation. To address this, it is crucial to gather comprehensive evidence that substantiates your condition and its impact on your ability to work.

Often, insurers require a detailed physician statement when you file a claim. This statement should thoroughly explain your diagnosis, treatment plan, and how your condition or injury affects your ability to work. Therefore, ensuring that your medical records are complete and up-to-date is essential to the success of your claim.

Before initiating any legal action against the insurance company, have all documents reviewed by an experienced lawyer. A lawyer can identify any gaps in your documentation and advise you on additional evidence that may be needed.

Filling a Legal Claim

In most cases, appealing an insurance company’s decision to deny a claim rarely works. Essentially, the same insurance company that initially rejected your claim will be handling the appeal. In our experience, most insurers use appeals to stall out the 2-year window you have to file a claim in court. That means you will not be in a position to seek compensation through a legal long-term disability claim.

Once you submit your application for long-term disability benefits, the insurance company will review your case and determine whether to award the benefits or spend money and other resources fighting your claim. This is why it is in your best interest to seek legal guidance and representation early enough. A knowledgeable disability lawyer can help avoid claim-related mistakes that could lead to claim denial in the first place.

Knowledgeable disability lawyers understand the tricks that an insurance company may use to reject legitimate applications for disability benefits in Ontario. Having an experienced lawyer on your side makes it possible to pursue an LTD claim successfully.

How Grillo Law can help

If a disability insurance company has rejected your application for benefits payments or your benefits have been terminated, our disability lawyers are ready to help. Over the decades, we have helped thousands of individuals in Ontario to get long-term disability benefits.

Indeed, we understand all processes involved in the pursuit of disability benefits. Some of our skilled disability lawyers have worked for insurers before. Thus, we understand how insurers operate, why they reject claims, and how we can successfully fight for your right to get disability benefits.

At Grillo Law, we offer free consultations. We also work on a contingency basis, so you do not need to pay us unless you get the compensation you are entitled to. Remember, if we are successful, the court may order the payment of the outstanding disability benefits from the time of claim denial. Schedule a free consultation and discuss your case with an experienced lawyer.

FAQs

What Conditions Qualify for LTD Benefits?

Most disability insurance policies cover a wide range of illnesses or injuries that prevent the insured from working. These can include physical disabilities, chronic illnesses, and mental health conditions. Consult a lawyer to understand the specific terms and coverage details of your policy.

Why Was My Claim Denied?

The denial letter will outline the specific reasons for your claim denial. Common reasons include insufficient medical documentation, lack of detailed physician statements, surveillance evidence that contradicts disability claims, or inadequate evidence of the disability’s impact on your ability to work.

 What Evidence is Necessary to Support an LTD Claim?

To support a long-term disability claim, you need comprehensive medical documentation, a detailed employment history, and specific information about your job, such as a job description. These elements help demonstrate the extent of your disability and its impact on your work capabilities.