Denied LTD Claim? Steps to Take After Long-Term Disability

It is not uncommon for a long-term disability claim to be denied in Canada or for long-term disability benefits to be cut off after an initial approval. And there are many reasons an insurance company may deny a claim.

However, if you have found that your LTD claim has been denied, there are steps you can take to appeal this decision. Our local personal injury lawyers will explain why such claims may be denied and which actions are needed in situations like this.

Common Reasons LTD Claims Are Denied

Some of the main reasons LTD claims are denied include a lack of medical evidence, missed deadlines, and an insurance company’s “own versus any occupation” interpretation.

In terms of a lack of medical evidence, insurance companies may state that insufficient medical documentation has been provided, especially for a health condition that requires more than a single test.

Generally, missing deadlines means you may have failed to submit the claim or additional documents on time, which is important because disability claims are subject to key timelines.

Yet, keep in mind that most denials are not final. You can take action to appeal the decision and, with the support of a personal injury lawyer, may be able to have the decision overturned.

Reviewing Your Policy & Gathering Evidence

It’s important to check and review long-term disability policy definitions as well as coverage limits. This helps you understand the policy and determine whether your condition qualifies as a disability in the context of long-term disability. You can check the policy definitions by locating the section on “Definition of Disability”.

It’s generally the case that the coverage limit falls between 60 and 70%. There may be a monthly cap to consider, too. For instance, if you earn $70,000.00 each year, but you have a monthly cap of $4,000.00, the $4,000.00 monthly cap applies. Normally, you can find this information in the section on “Schedule of Benefits”.

When making an LTD claim, you will need to gather evidence. The kinds of evidence you will require include the following:

• Complete medical documents: The documents should show your condition, symptoms, the severity of symptoms, how often you experience them, and why they affect your ability to return to work.
• Doctor’s notes: As well as office visit records and referrals that show physical exam findings and mental status observations, you need to gather specialist reports and objective test results, such as scans (if they apply to your health condition).
• Vocational assessments: Your vocational assessment can reflect your work history, transferable skills, physical ability, and additional details that can support your LTD claim.

Your claim forms need to match the information on the medical records. Generally speaking, inconsistencies such as admitting to your doctor that you feel okay and contradicting this statement in the long-term disability form can potentially result in a claim denial.

The Appeal Process in Ontario

Submitting an appeal requires a few steps, which our personal injury lawyers have outlined below.

• Review the denial letter: Reading the denial letter carefully can help you understand the exact reasons the insurance company has denied your claim. Generally, you then have up to two years from the date of the denial to proceed with legal action.
• Collect evidence: Collecting evidence such as updated medical records, specialist reports, and vocational expert opinions can help contradict the reasons for denial.
• Speak with a lawyer: A personal injury lawyer can review the denial, check whether the insurance company has misinterpreted the evidence, and help you build a robust case.
• Send an appeal letter: Drafting your written appeal and submitting it with the new evidence can initiate the process and show why the long-term disability claim denial was incorrect.

There is a difference between appealing through the insurance company and proceeding with an external legal claim. In the former, you normally ask the insurance company to check the denial again. This is done by a different claims examiner or senior specialist in the same insurance organization.

In the latter, you may take the insurer to court and proceed with an independent process that is reviewed by a judge. Independent expert evidence can also be introduced, such as medical experts or vocational professionals.

When You Should Take Legal Action

If you find that the insurer is ignoring strong medical evidence, or repeatedly questioning the credibility of your claim, that you are approaching the two-year limitation period, or have made repeated appeals and encountered repeated denials, it may be a good idea to take legal action and get the support of a lawyer.

Our experienced personal injury lawyers can negotiate with insurers after calculating the entitlements, obtaining medical records, and accessing independent medical opinions. Legal teams can also take the claim to court, filing the claim within the two-year limitation period.

Seek Support from Ristich Law as an LTD Client

If you have had an LTD claim denied, there are steps you can take. With Ristich Law’s evidence-driven approach, you can handle the appeal process and negotiate the benefits claim.

We offer a compassionate approach and work on a contingency basis, demanding no upfront costs from clients. Let us handle the insurance company while you focus on recovery. Manage your claim appeal with the support of Ristich Law.

Frequently Asked Questions About Denied Long-Term Disability (LTD) Claims

Why was my long-term disability (LTD) claim denied?

Common reasons include insufficient medical evidence, missed deadlines, inconsistencies in documentation, or the insurer’s interpretation of “own occupation” versus “any occupation.” Sometimes benefits are cut off after two years when the policy definition of disability changes.

2. What does “own occupation” vs. “any occupation” mean?

Most LTD policies consider you disabled if you cannot perform your own occupation for the first two years. After that, the definition often shifts to any occupation, meaning you must prove you cannot perform any suitable work based on your education, training, or experience.

3. What should I do after receiving a denial letter?

Carefully review the denial letter to understand the insurer’s reasons. Then gather updated medical records, specialist reports, and vocational assessments that address those concerns. Consistency between your medical records and claim forms is essential.

4. How long do I have to take legal action in Ontario?

In Ontario, you generally have two years from the date of denial to start a legal claim. Acting promptly helps protect your rights and ensures important evidence is preserved.

5. What is the difference between an internal appeal and a lawsuit?

An internal appeal asks the insurance company to reconsider its decision. A lawsuit involves taking the insurer to court, where a judge independently reviews the evidence and may consider expert testimony.

6. How can a lawyer help with a denied LTD claim?

An experienced personal injury lawyer can review your policy, identify weaknesses in the insurer’s reasoning, gather supporting medical and vocational evidence, negotiate on your behalf, and commence a claim within the limitation period if necessary.

Ristich Law handles LTD appeals on a contingency basis, meaning clients pay no upfront fees while focusing on recovery.