Denied Long Term Disability (LTD) Claim? How to Fight LTD Denial
In Ontario, most legitimate long-term disability (LTD) claims are rejected by insurance companies. In fact, industry statistics show that around 60% of all long-term disability claims are denied each year.
Most of the time, an LTD applicant will receive a letter from the insurance company informing him or her of their claim’s denial and inviting them to appeal the insurance company’s decision. This is done in the hopes that the insurance company can handle matters directly with the applicant to avoid a lengthy legal battle.
However, at this time, it’s important to stop and learn more about your rights, before moving forward with the appeals process. Taking this time is often worth it since liaising with the insurance company without a lawyer can be tough. That’s why you should consider hiring a representative to help you appeal the insurance company’s decision.
The LTD appeals process can be complex and very difficult to handle if a person is not familiar with the denial process and the various steps one must take to maximize their position at the negotiation table.
To that extent, the following guide will walk you through the appeals process in case your long-term disability claim is denied by your insurance company.
Within this guide you will find information on the following:
- Common Reasons LTD Claims Are Denied
- Filing a claim late
- Failure to communicate with the insurer
- Contractual exclusion clauses
- Insufficient medical evidence
- Lack of “objective evidence” of disability
- Refusal to attend an independent medical assessment (IME)
- Refusal to submit to reasonable medical treatment
- Failure to participate in rehabilitation or return to work
- A change in the definition of what is considered “totally disabled”
- Credibility issues while assessing your claim
- Credibility issues due to the social media investigation
- Ineligible medical conditions
- The insurer contests your medical condition or severity
- Insurer Error
- Appealing Long-Term Disability Denial in Ontario
PLEASE NOTE: This guide has been developed based on our years of experience and expertise to be as precise and complete as possible! This information, however, is solely intended to educate and enlighten Canadians; it is not intended to replace the Canada Revenue Agency’s official documentation on the LTD. As a result, we suggest that you use it wisely!
Common Reasons LTD Claims Are Denied
As with any LTD claim, it is critical to submitting all favorable evidence in order to have the best chance of success. Especially when your LTD claim could be denied for a variety of reasons, including if you were unable to provide a physician’s statement, if you didn’t have a referral from a doctor, or if you were unable to provide an accurate diagnosis. Given that many insurance companies actively seek evidence or justifications to question or outright deny your claim, they will make you a significantly smaller offer than you deserve.
However, if you have the correct documentation or evidence, your claim may still be successful. This is where having an experienced long-term disability lawyer on your side may help. That being stated, it is only by recognizing these factors that we may begin to increase your prospects of success for any future LTD claims.
Despite the fact that each long-term disability claim is unique, insurers often have a set of conventional justifications for dismissing or terminating long-term disability claims. As such, some of the key reasons why LTD claims may be denied are as follows:
- Filing a claim or appeal late: LTD insurance policies often include a “Proof of Claim” or “Notice” clause, indicating a specific timeline under which an LTD benefits claim should be submitted to the insurance company, beginning from the point you first became disabled. As such, any claim that is filed late can be denied by the insurance company on the basis of these clauses. Thus, it’s essential that you take note of any deadlines when filing and appealing your claim. Given that, most individual plans and all group plans controlled by ERISA allow you to appeal an initial refusal within 180 days. If you fail to exhaust your administrative appeals during the 180-day period, you will be unable to sue your insurer in federal court.
- Failure to communicate with the insurer: Most insurance companies have an obligation to continue to adjudicate a claim on an ongoing basis. As such, the insurance company will continue to communicate with you to obtain updated information and medical records even after your claim has been approved. This is to ascertain whether or not you continue to meet the tests for disability under your LTD policy. If the insurance company has attempted to communicate with you on multiple occasions and received no response on your behalf, this may give them cause to deny or terminate your benefits.
- Contractual exclusion clauses: One of the most common reasons for rejecting claims based on a contractual exclusion is the “pre-existing condition exclusion clause.” As such, if the insurance company determines that you saw a doctor or sought out treatment related to your disabling condition prior to your insurance taking effect (typically the one-year period after the effective date of coverage), the insurer may deny your claim based on the pre-existing condition exclusion.
- Insufficient medical evidence: “Insufficient Evidence to Support Disability” can occasionally signify that the insurance company disagrees with your doctors’ assessments of your disability. As such, your application may have been sent to an internal medical consultant for assessment, and that consultant does not believe your medical condition is severe enough to meet the Long Term Disability (LTD) benefits criteria, resulting in the denial of your claim.
- Lack of “objective evidence” of disability: In cases where your condition cannot be verified through diagnostic imaging or “objective” tests of any kind, such as x-rays, MRI’s, blood tests, and so forth. The insurance company may then argue that your symptoms are self-reported and therefore cannot be assessed, thus resulting in the denial of your claim.
- Refusal to attend an independent medical assessment (IME): Many LTD insurance policies allow the insurer to have you assessed by a medical practitioner of their choosing for a medical or psychiatric evaluation. In which case, if the IME doctor determines that there is an absence of disability or acknowledges disability but indicates that accelerated recovery has occurred, it may result in the denial of your claim. Likewise, any refusal to attend an IME arranged by the insurance company will often be accompanied by the termination or denial of LTD benefits.
- Refusal to submit to reasonable medical treatment: Most LTD insurance policies require that you submit to medical treatment as a condition of receiving benefits. As such, if you refuse to submit to reasonable medical treatment, your LTD claim may be denied or terminated.
- Failure to participate in rehabilitation or return to work: As part of the LTD insurance policy, you are obligated to make reasonable efforts to rehabilitate. That is, if your benefits have been approved, your case manager may request the services of a rehabilitation consultant to formulate a rehabilitation program. If you are unable to participate in a rehabilitation program or return to work program for whatever reason, this could result in the termination of benefits.
- A change in the definition of what is considered “totally disabled”: Usually, there are two definitions of disability for all LTD policies. For the first 24 months, a person must be disabled from performing the essential activities of his or her own occupation, according to the initial definition of impairment. After 24 months, the test is whether the person can execute the essential functions of any gainful activity for which he or she has the necessary education, training, and experience. The wording of these definitions depends on the plan or policy. That being said, it is common for insurance companies to terminate claims at the change of definition, given that they feel you are able to perform different occupations, if not your own.
- Credibility issues while assessing your claim: While assessing your claim, it is within the insurance company’s right to hire a private investigative company to conduct surveillance without your knowledge. This is done in an effort to gather evidence to dispute your disability by proving that you are capable of working. Considering that you appear to be engaging in tasks similar to work activities or are able to sustain certain positions or a routine. In which case, they may use this evidence to deny or terminate your claim.
- Ineligible medical conditions: Individual and group long-term disability insurance issued by employers may not cover all disabilities. Some only cover specific diseases that are outlined in a benefit schedule. Exclusions are frequently used to exclude coverage for situations that the insurer decides not to cover, such as war, self-inflicted injuries, and crime-related impairments.
- The insurer contests your medical condition or severity: Even if you have a disability, certain factors typically result in a claim denial or coverage limitation. Doctors frequently treat fibromyalgia and migraines based on subjective symptoms. Insurers have a tough time providing compensation for this and other “self-reported” ailments. When a physician cannot objectively confirm your condition, you must produce compelling, convincing proof that supports your claim and incapacity to work.
- Insurer Error: When a claim agent declines your claim, you must demand a thorough explanation. Insurance claim agents differ in their expertise and experience. They occasionally make crucial blunders since there are so many complex policy regulations and medical difficulties. Group insurers must also adhere to ERISA claim standards and individual policies in accordance with their government’s Unfair Claim Settlement Practices Act. The regulations often compel claim handlers to make decisions on claims within a specific time period. This frequently causes them to make mistakes or make judgments before they have all of the necessary facts.
Listed above are just a few of the many common reasons why your LTD claim may be denied. However, if you have any difficulties confirming your eligibility for LTD benefits, the specialists at Disability Credit Canada are here to assist you in getting your claim approved.
NOTE: You do not have to take a denial as the last word on your claim, contrary to popular belief. Rather, you have the option of hiring a disability lawyer to file an appeal on your behalf in order to secure LTD compensation.
Appealing Long-Term Disability Denial in Ontario
You will receive a letter from your insurance carrier suggesting a decision on your claim shortly after filing for LTD benefits. If your claim has been denied or terminated for any reason, do not assume that the insurance company is correct in its decision. There might be a number of reasons why their judgment is incorrect and should be contested. Most of the time, you will have two alternatives for contesting the insurance company’s decision. These are as follows:
- The first option is to file an internal or external appeal with the insurance company. You can file an appeal up to three times, depending on the language of the policy. That being said, each appeal must be filed within 90 days of the ruling. It is crucial to note that appealing the judgment is not the best option unless your physician can give considerably different data to support your claim.
NOTE: If your LTD application is denied, you should consider consulting an LTD lawyer or paralegal immediately. As there are strict deadlines for filing an LTD appeal, an experienced lawyer or paralegal can greatly increase your chances of having your claim approved. Additionally, they can further help you to better understand the terms and language used in your denial letter, which will play a significant role in making your appeal.
- The other alternative is to file a lawsuit against the insurance company for wrongful disability benefits denial. It is preferable to retain legal assistance in order to attain the best results. This will relieve you of any stress and allow you to concentrate on your rehabilitation.
NOTE: Even if your claim is denied, it is critical that you continue to receive treatment and pursue the best treatment alternatives for your disease. This will provide your doctor(s) with the information they need to continue to establish your limitations as well as document any persisting problems that prevent you from returning to work. Furthermore, the LTD lawyers will be able to obtain the necessary supporting documentation to refute your claim’s denial.
Disability Credit Canada specializes in disability applications such as long-term disability (LTD) claims.
We’ve helped hundreds of Canadians with their CPP-Disability and Disability Tax Credit applications. Allow us to assist you in obtaining long-term disability benefits today! Don’t wait to be denied by your insurance company. Rather, come prepared and get yourself approved the first time around.
If you are interested in applying for LTD benefits or if your application for LTD benefits has been denied, please contact us @ 1-844-800-6020 for a free assessment of our services. If we can’t, nobody else can help you get approved!