Why your Long-term Disability Claim may be Denied

The purpose of long-term disability coverage is to provide income replacement when you are too sick or too injured to work.  Many Canadians have long-term disability (LTD) coverage through their employee benefits plan, but self-employed persons and others who aren’t covered through a group plan, must obtain individual LTD coverage from a disability insurer.

Unfortunately, LTD insurance providers sometimes deny benefits to persons who are genuinely disabled and unable to do their job due to the effects of an extended illness or injury.  This circumstance typically places a huge financial burden on the claimant and their family, in addition to the stress and challenges brought on by their medical condition.

When benefits are denied, you naturally want to resolve the situation as quickly and painlessly as possible, and claimants have two options for appealing a denied claim: you can continue to appeal your claim through the insurer’s internal appeal process, or you can seek representation from a disability claims lawyer.   At Dietrich Law, our disability claims lawyers have successfully resolved many disability claim disputes for clients who were unable to work but had their long-term disability claim unfairly denied or terminated.  Additionally, our expertise and knowledge of the disability claims process enables us to give you a realistic assessment on the viability of making a successful claim given the circumstances of your disability and to help determine what, if any, further evidence is needed.

If your LTD claim was denied, it’s important to carefully read your denial letter so that you fully understand the reason for denial and know the deadline for appealing your denied claim.  If the claim was denied due to a failure to include medical documentation or tests, or because the insurer requests clarification from your doctor, you may be able to resolve the oversight fairly quickly, assuming they agree, by obtaining the necessary information and submitting it with your appeal.  If the reason appears unclear or vague, you should call your disability claims representative to obtain a clear understanding of what was lacking or deemed problematic in your claim.  

Here are the most common reasons why a long-term disability claim may be denied.

1. You have not been under the regular care of a doctor for your medical condition or were not following your doctor’s advice for treatment.  LTD insurers expect that claimants are doing their best to improve or resolve their disability before applying for LTD coverage and they expect to see regular doctor’s visits, regardless of whether these visits help to improve the situation.
2. You did not submit medical records or medical tests that substantiate your condition - if you have a condition that can be verified though an X-ray, CT scan, MRI or other medical test, you need to submit the test results with your claim.
3. You have a condition that cannot be proven through objective tests (such as fibromyalgia or depression), but you haven’t been diagnosed or treated by a medical professional who has expertise in the particular condition, such as a chronic pain specialist, rheumatologist or psychiatrist.
4. You have not fully answered all the questions on the LTD application.
5. Your condition doesn’t meet the definition of a ‘total disability’.  This test varies but generally LTD insurers require that, to qualify for LTD benefits within the first 2 years, the disabled person must be unable to perform the essential duties of their own job.  In order to be eligible after 2 years, a disabled person must be unable to perform the essential tasks of any job for which they are suited by way of education, training or experience.
6. Your doctor’s opinion letter did not provide specific details on how your medical condition prevents you from performing the essential tasks of your job. 
7. Your disability is excluded under the terms of your LTD policy.  A disability may be excluded under the pre-existing condition clause of your LTD policy, if it is associated with drug or alcohol use, and failure to seek treatment, or for other exclusionary reasons named in your policy.
8. You missed the deadline for making a claim or for appealing your claim.

In any of the following circumstances, you are far more likely to obtain owed benefits if you seek advice and representation from a disability claims lawyer who has proven experience winning claim disputes against LTD insurers:

• you’re unable to have your LTD claim overturned or your benefits reinstated simply by supplying the medical reports or information requested by your LTD insurer;
• the reason for your denied claim continues to be unclear;
• you disagree with the stated reason for denial; or
• the insurance company continues to dig in its heals and deny your legitimate claim

Keep in mind that insurance companies are in the business of making money and they often deny disability coverage for legitimate claims.  Bearing that in mind, don’t give up on your claim without a fight or without strong representation.