Long-Term Disability Claims & Appeals: What You Need To Know

If you are a Canadian resident living in Ontario who has an insurance plan through your employer and has a permanent disability or a serious and long-lasting medical condition that prevents you from working, you may be eligible to receive financial assistance in the form of Long-Term Disability (LTD). 

It is important to note that Long Term Disability benefits are usually a part of a private insurance plan that an employee buys and pays into through his/her employer and it is not a government disability plan such as CPP Disability.

In this article, we will be introducing you to the Long-Term Disability Insurance Benefits in an effort to help you gain a greater understanding of the following: 

1. What is Long-Term Disability in Ontario?
   • What is Long-Term Disability Insurance?
   • Long-Term Disability Benefits
2. Types of Long-Term Disability in Ontario
3. How Much Do Long-Term Disability Benefits Pay in Ontario?
4. What Medical Conditions Qualify for Long-Term Disability Benefits?
5. Common Types of Disabilities Covered by LTDI
6. How to Apply for Long-Term Disability in Ontario
   • Step 1: Determine The “Waiting Period” For Your LTDI Plan
   • Step 2: Ensure That You Have the Support of Your Doctor
   • Step 3: Inform Your Insurance Company of Your Intent to Apply
   • Step 4: Fill Out & Complete the LTD Application Package
   • Step 5: Submit the Completed LTD Application Package and Any Supporting Documentation to the Insurer
   • Step 6: Cooperate with Any Reasonable Requests from Your Insurer
   • Step 7: Wait for the Insurance Company’s Decision on the Status of Your Application.
7. Is It Hard to Get Approved for Long-Term Disability Insurance?
8. Can I Apply for Long-Term Disability on My Own?
9. Do I Need a Lawyer or Paralegal If My LTD Claim Was Denied?
10. Common Reasons LTD Claims Are Denied
11. What to Do If the Insurance Company Denies Your LTD Claim
12. Summary

 

What is Long-Term Disability in Ontario?

Long-Term Disability (LTD) is a type of income replacement benefit that provides you with a percentage of your income if you are ill or injured and thus “totally disabled” for an extended period of time. It is also a legal term, often used in long-term disability insurance (LTDI) policies to dictate the eligibility for benefits under the policy. Most insurance policies state that you must have a medical condition that causes a long-term disability, which must be serious and long-lasting. Additionally, it should prevent you from performing the regular duties of your job or any type of work for at least 3 months. Respectively, you must be off work for 17 weeks or more for your situation to be considered a “long-term disability.”

 

What is Long-Term Disability Insurance?

Long-Term Disability Insurance (LDTI) is a common type of income protection. Its purpose is to provide financial assistance to covered plan members in the event that they are no longer able to go back to work for 3 months or longer. Whether due to an accident, illness, or injury that may result in a “long-term disability” as defined by the insurance policy. 

Depending on the nature of the disability, most long-term disability insurance plans will pay monthly benefits up to age 65. Making long-term disability insurance a smart investment for any healthy, employed individual, interested in securing their financial future.

Long-term disability insurance can be sold either as part of a group insurance policy (“group benefit”) through your employer or separately. However, it’s important to note that, in these cases, many employers will either pay all of their employees’ monthly premiums or require that they contribute to all or part of their LTD coverage. Alternatively, you can purchase a private (individual) long-term disability policy from an insurance broker. Such LDTI policies are often sold to self-employed professionals or business owners.

 

Long-Term Disability Benefits

Long-term disability benefits are a type of income replacement benefit. Under an insurance policy, long-term disability benefits are typically paid on a monthly basis, often with a maximum payment amount as outlined in the disability policy. Most long-term disability plans will replace 60% to 85% of your normal income. Consequently, in order to qualify, you must meet all employment and disability requirements.

Some plans may provide disability benefits for up to two years if you’re unable to return to your previous place of employment. However, after two years, you might only continue to receive monthly benefits if you are deemed “totally disabled” and are thus permanently unable to return to work of any kind.

NOTE: If you are currently receiving any short-term disability benefits, such as EI Sickness Benefits, you will only begin to receive any LTD benefits once these have concluded.

 

Types of Long-Term Disability in Ontario

There are several types of long-term disability benefits available in Ontario. Some are offered by the Provincial Government while others are offered by the Federal Government and private insurance companies (health or life insurance brokers). They are as follows:

• Long-Term Disability Insurance (Employer Group Plans, Private/Individual LTDI Policies)
• Canada Pension Plan Disability (CPPD)
• Workers Compensation (WSIB)
• Ontario Disability Support Program (ODSP)
• Disability Tax Credit (DTC)

 Each of these disability plans represents a different type of income replacement benefit. Therefore, they differ from one plan to the next with regards to their eligibility criteria and the type of benefits you can receive upon being covered by them, once approved.

 

How Much Do Long-Term Disability Benefits Pay in Ontario?

In Ontario, long-term disability insurance is an important form of financial protection that provides payments if you’re incapable of working due to a covered accident, illness, or injury. On average, LDTI replaces between 60% and 85% of your base salary, up to a maximum amount (mentioned in your policy) for a specified time, usually until an individual is well enough to resume work or a specified coverage period (usually age 65) if you are:

• Temporarily unable to work, or
• “Totally disabled,” due to an injury or illness  

Additionally, you may also have offsets that might reduce your LTD benefits. Considering that, some LTDI policies include specific clauses regarding your maximum benefit amount. As such, if you receive payments from another source like CPP Disability Benefits or WSIB Benefits, then they may weigh your other sources of income or financial benefits, which could result in a reduction to your LTD benefits. 

If your LTD claim is approved, the insurance company will notify both you and your employer of the benefit payment start date and the approved amount for benefits. Your payments will begin from the date the ‘elimination’ period (‘waiting’ or ‘qualifying’ period), is completed. The “elimination” period is unique to every insurance policy, though it often ranges from 4 months to 52 weeks. What is more, your monthly LTD benefits may see a cost-of-living adjustment (COLA) each year due to inflation. This may increase your benefits by 1% to 3%, depending on several factors.

NOTE: Your insurance provider may be able to help you calculate the offset amount based on your other benefits.

 

What Medical Conditions Qualify for Long-Term Disability Benefits?

Most illnesses or injuries qualify you for long-term disability in Ontario. Considering, that disability insurance claims aren’t based on a diagnosis. Rather, their approval is focused on the disability caused by your medical condition. However, it’s important to note that how a policy defines “disability” will determine how much, and even if, you are able to collect LTD benefits following an injury or illness.

For instance, you can have a serious illness, such as Multiple Sclerosis (MS), but not be considered “totally disabled,” at least not right away. However, some insurance companies may cover you regardless of the severity or type of illness or injury that you may be suffering from. That is, if you have a disability that prevents you from performing all or at least most of the duties required by your current job.

That being said, a diagnosis alone is not enough to grant approval of LTD benefits. Yet, insurance companies still require a solid diagnosis when making a claim. A solid diagnosis largely shapes your treatment plan, which is also required by insurance companies to approve a claim. It is important to note that your insurance company has to sign off on the designated treatment plan. If they disagree with your treatment plan, they can deny your claim or stop your payments.

NOTE: Some policies may exclude the coverage of current injuries or illnesses that are covered under WSIB.

 

Common Types of Disabilities Covered by LTDI

In Ontario, each long-term disability insurance (LDTI) policy differs from one to the next. Considering that every insurance company has its own definition of what qualifies as a “disability,” which will determine what, if any, benefits you might receive. That being said, some disability insurance policies will still pay out a monthly benefit as long as your injury or disability prevents you from working at your normal job. Regardless of whether or not you are still able to perform other types of work. Meanwhile, other policies will not pay benefits if you can work in another type of profession, even if you earn less money.

Moreover, it’s important to note that certain illnesses are excluded from many disability insurance policies. In these cases, to be eligible for LTD benefits such as income replacement and medical treatment coverage, your medical condition or injury must meet the insurance policy’s definition of “disability“.

Some illnesses and injuries that qualify as a “disability” under most insurance policies are as follows:

• Musculoskeletal Issues (Arthritis, Sciatica, Scoliosis, Fibromyalgia, Carpal Tunnel, Spinal Stenosis, Back, Degenerative Disc, etc.)
• Personal Injuries (accident, slip, fall, penetrating head injury, brain injury, trauma, fractured spinal injury)
• Chronic Pain (back pain, Fibromyalgia, Arthritis, IBS, Nerve Pain, Sciatica)
• Mental Health and Psychological Illnesses (PTSD, Depression, Schizophrenia, Bipolar Disorder)
• Cardiovascular Conditions (Hypertension, Chronic Heart Disease, Heart Attack, Stroke, Coronary Artery Disease)
• Neurological Disorders (Stroke, Parkinson’s Disease, Multiple Sclerosis, ALS, Epilepsy)
• Respiratory Conditions (COPD, Chronic Lung Disease, Asthma)
• Cancer
• Diabetes

NOTE: When deciding on an LTDI plan, it is our recommendation that you check with the provider or insurance agent to determine what constitutes a “disability” under that plan.

 

How to Apply for Long-Term Disability in Ontario

To file an LTD claim in Ontario, you must be covered under a Long-Term Disability Insurance plan through your employer or an independent insurance broker, followed by being off work for an extended time. There are seven key steps to applying for long-term disability, which are as follows: 

1. Determine the “waiting period” for your LTDI plan.
2. Ensure that you have the support of your doctor.
3. Inform your insurance company of your intent to apply.
4. Fill out and complete the LTD application package.
5. Submit the completed LTD application package and any supporting documentation to the insurer.
6. Cooperate with any reasonable requests from your insurer.
7. Wait for the insurance company’s decision on the status of your application.

 

Step 1: Determine The “Waiting Period” For Your LTDI Plan

The first step to applying for LTD is to determine the “waiting period” of your insurance policy. Provided that, you can start your application before the waiting period ends. This ensures that you will receive your benefits immediately after the “waiting period” has concluded and your application has been approved. The “waiting period” simply refers to the duration of time you must be off work for your disability to be considered “long-term.” The ‘waiting period’ for the majority of LTD plans ranges anywhere from 17–22 weeks. However, to determine the “waiting period” for your specific LTDI plan, please refer to your insurance policy or group benefits booklet.

 

Step 2: Ensure That You Have the Support of Your Doctor

After you have determined the “waiting period” of your insurance policy, it’s important to consult your doctor to ensure that you have their full support in applying for LTD benefits. Seeing as if your doctor disagrees with your decision to apply, it is likely that your application will be denied. Thus, a firm conversation with your doctor is needed to know for certain if they will recommend that you stay off work after the “waiting period” expires. If you manage to obtain the full support of your doctor or figure out an alternative, you can then begin moving forward with the application process.

 

Step 3: Inform Your Insurance Company of Your Intent to Apply

Once you have the approval of your doctor, next you’ll need to notify your insurance company of your intent to apply. Considering exactly how to apply for LTD benefits varies from plan to plan. Thus, you will need to have a conversation with your insurer to determine the next steps for applying.

 

Step 4: Fill Out & Complete the LTD Application Package

After speaking with your insurance company and determining the next steps, you will need to obtain a copy of the LTD application package. Most application packages are available through your employer, Union Rep, HR Rep, Insurance Broker, or the insurer themselves. After that, you will be required to fill out and arrange for each form within the application package to be completed, in an effort to prove that you are “totally disabled” as is defined by your insurance policy.

The application package includes 3 main forms. Those are as follows:

• Notice of Claim—Filled out by the Claimant
• Employer’s Report—Filled out by the Employer
• Medical Report—Filled out by the Appropriate Medical Practitioner

 

Step 5: Submit the Completed LTD Application Package and Any Supporting Documentation to the Insurer

You can submit your claim, along with any supporting documentation, to the insurance provider for approval once all application documents have been signed and completed by the proper party. Ideally, you should send your application, along with all supporting documentation, in one package. This package should include the following:

• Your application form was completed and signed
• An additional sheet is attached to the application form for any supporting documentation that wouldn’t fit on the form.
• The medical form was completed and signed.
• The employers’ form, was completed and signed.
• The cover letter

NOTE: You might not always have the option to submit all documentation at once. Considering that some doctors and employers prefer to submit their forms (medical & employer’s forms) directly to the insurance company. However, in any case, we recommend that you submit your forms as soon as possible, to at least get the application process started.

 

Step 6: Cooperate with Any Reasonable Requests from Your Insurer

When qualifying for long-term disability, you should always have a cooperative approach. As such, any reasonable request, that is, what the court would determine as reasonable under the circumstances, should be met in good faith. The following are some of the common requests you might see upon submitting your application:

• To speak with the insurance company over the phone to answer any questions that they might have
• To provide the insurance company with copies of your medical records.
• To ask your doctor to provide the insurance company with more information.

 

Step 7: Wait for the Insurance Company’s Decision on the Status of Your Application

After you have gone through steps 1-6, as mentioned above, the final step in applying for LTD benefits is to wait for the insurance company’s decision regarding the status of your application. In this case, you may be informed by a representative over the phone, though usually, you will receive an email or letter in the mail indicating your application’s status. This process usually takes anywhere from 30 to 60 days for the insurance company to make its decision. However, this can be extended if the employer or medical forms get delayed, or if you are delayed in filing the insurance company’s other requests for information.

If your application is approved by the insurance company, it is important that you read over the approval letter carefully. Considering that, on occasion, an application may only be approved on a temporary or conditional basis. For instance, in cases where there is outstanding information required for submission before the deadline, as indicated in the approval letter.

However, if your application is denied for whatever reason, it is within your right to ask them to reconsider your application for approval. This is accomplished by way of an appeal. At this stage in the application process, we recommend that you consult with us or another disability law firm before submitting your appeal. The right approach for an appeal is different for everyone, and as such, it needs to be done strategically to maximize your chances of success.

 

Is It Hard to Get Approved for Long-Term Disability Insurance?

Many LTD policies have two definitions that must be met to receive payments. The first step is to demonstrate that you are unable to perform the work you were performing prior to the beginning of your condition. This test later progresses to being unable to perform the duties of any comparable occupation. Unfortunately, filing an LTD claim can prove challenging for those looking to apply. Given that the odds of having your claim approved depend on a number of factors, those factors are as follows:

• How your insurance policy defines “disability”
• The type of disability insurance policy (group or individual)
• The type of disability you are suffering from, with regards to your ability to perform the regular duties of your job,
• The frequency in which you see your doctor
• The frequency with which you seek out treatment 

That being said, when applying for LTD, industry statistics suggest that while most claims are accepted, many legitimate claims are rejected. In fact, it can be estimated that 60% of LTD claims are denied per year. Considering that many insurance companies will actively find evidence or arguments to challenge or outright deny your claim if not, they will provide you with a much lower offer than what you deserve. Although, with the right documents or evidence, your claim can still be successful. However, this is where having an expert long-term disability lawyer on your side can be beneficial.

NOTE: It’s crucial to remember that, contrary to popular belief, you don’t have to accept a denial as the final word on your claim. Rather, you have the right to enlist the assistance of a disability lawyer to file an appeal on your behalf to receive LTD benefits.

 

Can I Apply for Long-Term Disability on My Own?

Ultimately, when applying for LTD, whether you choose to apply on your own or with the help of a disability insurance lawyer is up to you. However, it is important to note that regardless of how you choose to apply, you should always be aware of your rights to maintain control over your claim. This is especially true when negotiating directly with the insurance company. Considering that insurance companies have years of experience in how to manage and settling losses, they are almost always working on behalf of their shareholders. As such, you may have a greater chance of getting your claim approved with the assistance of a disability lawyer. Because disability insurance lawyers often have the experience and knowledge required to offset that of the insurance companies, your chances of success are increased.

NOTE: Because there are deadlines for bringing a claim against your disability insurance provider, you should contact an experienced lawyer as soon as your disability claim is refused.

 

Do I Need a Lawyer or Paralegal If My LTD Claim Was Denied?

If at any point, your LTD claim is denied by the insurance company, consulting a disability lawyer or paralegal to contest your LTD benefits denial is your best chance at advancing your claim. Considering that it takes extensive skill and experience to combat the evidence gathered by the insurance companies to dispute your disability. 

What is more, disability lawyers and paralegals have a network of medical specialists with whom they work closely and who understand how critical the diagnosis is to your case. Not to mention, a long-term disability lawyer takes the time to understand the specific circumstances of your case and gather the necessary evidence that proves your behavior, as well as how your ability to perform daily activities has been impacted since you became disabled. By hiring an LTD lawyer, you’re ensuring that your rights are protected and that you get a fair settlement from the insurance company.

That being said, if you happen to seek outside assistance for your LTD claim, you are better off enlisting the help of an advocate or LTD firm (paralegal), such as Disability Credit Canada Inc, versus an LTD lawyer, as they work solely on a no-win, no-fee basis, with no additional fees. Whereas when enlisting the help of an LTD lawyer, there are a variety of extra fees you wouldn’t usually face when applying for LTD benefits. Most of these extra fees come from lawyers taking over a larger portion of the application and appeals process.  

 

Common Reasons LTD Claims Are Denied

As is the case with every LTD claim, it is important to ensure all favorable evidence is presented for the claim to have an optimal chance of success. Especially when there are a variety of reasons why your LTD claim may be denied. That being said, it is only through understanding these reasons that we can begin to improve your chances of success for all 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:

• Failure to file a claim on time 
• 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

Listed above are just a few of the many common reasons why your Long Term Disability 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.

 

What to Do If the Insurance Company Denies Your LTD Claim

Shortly after filing for LTD benefits, you’ll receive a letter from your insurance company indicating a decision on your claim. If your claim has been denied or terminated for any reason, do not assume that the insurance company is correct in its decision. There could be a variety of reasons why their decision is incorrect and can be challenged. Most often, you will have two options on how to go about fighting the insurance company’s decision. Those are as follows:

1. The first option is to file an internal or external appeal with the insurance company.  
2. The second option is to file a lawsuit against the insurance company for wrongful disability benefits denial.

 

Summary

Disability Credit Canada specializes in disability applications such as Long-Term Disability (LTD) claims. 

We’ve assisted hundreds of Canadians with the CPP disability and the Disability Tax Credit. Allow us to help you get approved for Long-Term Disability Benefits today! 

If you are interested in applying for LTD benefits or if your LTD application has been denied, please call us at @1-844-800-6020 for a free assessment of our services. If we can’t assist you in getting approved, then nobody can!