Living with a disability can be challenging, both physically and financially. This is especially true in a city as expensive as Toronto if your disability prevents you from working and you need to take an extended amount of time off work.
If you’re covered by an insurance policy for long-term disability benefits, getting that financial support isn’t as easy as it may seem. Don’t take chances; partner with one of the top disability lawyers in Toronto who knows what it takes to make the insurance company honour their contract.
Generally speaking, these are the criteria needed to qualify for LTD benefits (keep in mind each insurance policy may be slightly different).
How Severe Does an Illness or Injury Have To Be To Qualify for Long-Term Disability?
If your medical condition satisfies the criteria for what is typically referred to as a “total disability,” you may be eligible for long-term disability benefits unless it is specifically excluded in the LTD policy or it is a pre-existing condition.
Total disability does not mean that you are literally unable to function or have endured a life-threatening injury. Total disabilities are defined and categorized in two ways.
An “Own Occupation” Total Disability
This generally means that you are no longer able to carry out the essential, routine duties of the job you held when you became disabled because of your medical condition.
An “Any Occupation” Total Disability
This is the classification of your disability if it renders you incapable of performing the tasks of any job for which you may already be qualified for due to your experience, education or training or for which you may become qualified with proper training.
Your insurance policy may utilize either categorization as the minimum requirement for eligibility when you apply for LTD payments. But if your LTD insurance covers an ‘own occupation’ disability, your policy probably stipulates that in order to continue receiving benefits after two years, you must be totally disabled according to their ‘any occupation’ definition. If not, your LTD payments will cease.
Many people insured by an LTD policy assume that this stipulation is integral to the contract, and the thought of challenging it doesn’t even cross their minds. This is a major misconception.
If you receive a letter saying that you no longer qualify for LTD benefits because of this stipulation, speak to a disability lawyer as soon as possible. LTD lawyers challenge this change in definition and can often force the insurance company to continue paying the LTD benefits.
What Types of Conditions Are Covered By Long-Term Disability Insurance?
Generally speaking, having a disabling condition that meets the definition of either an ‘own occupation’ or an ‘any occupation’ total disability qualifies you for LTD benefits. Common medical conditions that are covered by LTD insurance include:
- Chronic conditions like Chronic Fatigue & Chronic Pain Syndrome.
- Back, muscle and joint disorders such as Rheumatoid Arthritis, Fibromyalgia and Osteoarthritis.
- Mental illnesses including Depression, PTSD and Anxiety.
- Cardiovascular conditions such as heart disease & Stroke.
- Cancers and tumours.
- Spine and Nervous System Disorders such as Multiple Sclerosis, Epilepsy and Alzheimer’s Disease.
- Digestive disorders including Crohn’s Disease, IBS and Ulcerative Colitis.
- Injuries from accidents that cause fractures, burns and brain injuries.
These are just examples. If you are diagnosed with a medical condition, and you are unable to complete basic functions at work, but you’re not sure if your condition is covered, you can ask your insurance company or speak to a disability lawyer for advice on the likelihood of a successful claim.
Filing a Claim for Long-Term Disability Benefits
An application package for long-term disability benefits usually includes the following:
- Claimant’s Statement – You’ll likely have to describe your medical condition and include information about when it started, how it affects your capacity to work and your medical history.
- Physician’s Statement – This form must be filled out by your primary care physician. They must include details about your medical history, when you started treatment, their diagnosis and prognosis, how you’ve reacted to therapy, etc. This assertion is essential to your case, and your doctor must offer medical proof to back up their recommendation that you cannot or shouldn’t be carrying out your work duties.
- Employer’s Statement – Your employer will fill out this section detailing your job title, responsibilities, compensation, length of the absence, any conflicts at work and other employment-related details. They may be asked to send it directly to the insurance provider, so it would not be a part of the package you submit.
After submitting a claim, you can wait anywhere from 30 to 90 days before receiving a decision. If your claim is denied, this doesn’t necessarily mean that you do not qualify for LTD benefits; insurance companies routinely deny claims to try and increase their profitability.
Reasons Commonly Used By Insurance Companies to Deny LTD Claims
Insurance companies use a number of ‘boilerplate’ reasons for rejecting claims, even though many of them are worded to sound as though they are based in medical science and are intended to make you give up on your claim. It’s imperative that you don’t just accept the insurance company’s reasons for their denial decision, especially if you have a legitimate claim. Instead, speak to a disability lawyer in Toronto right away.
LTD lawyers come across these reasons daily and know how to challenge them to get you the benefits you deserve.
You Are Trying to Claim a Pre-Existing Medical Condition
Insurance companies often reject requests for LTD benefits by citing an incident in your medical history that occurred before the start of the policy and asserting that it is evidence that your condition is actually a pre-existing condition that you failed to disclose when you first applied for the policy.
Your Condition Does Not Meet the Definition of a Total Disability
If your LTD claim is denied for this reason, it is often the position of the insurance company that either your application failed to show a direct link between your symptoms and your inability to complete your work or that you should be able to perform your work if your employer provides you with reasonable accommodations to assist you.
Not Enough Medical Evidence to Support Your Claim
If your application didn’t include enough evidence to back up your statements, the insurance company will use this as grounds to deny your LTD claim. Insurance companies also insist that they require “objective evidence,” like x-rays, blood tests and MRIs, before approving a claim.
This reason for denial is often used to deny claims for what are known as “invisible injuries.” This term generally refers to mental illnesses, but it also applies to physical conditions like fibromyalgia, IBS, chronic pain and others for which there is no test or “objective evidence” to prove the condition.
What to Do If Your LTD Claim is Denied
As soon as you receive a refusal letter, consult an LTD lawyer. Regardless of the insurance company’s justifications, an LTD lawyer can still obtain your benefits for you, but you only have a limited amount of time to do so.