Answers to frequently asked questions about Long Term Disability (LTD) claims


Every claim is different. The answers to the questions below, may not be true for everyone and should not be considered legal advice. To answer questions related specifically to your claim, we encourage you to reach out to us to answer your questions about your claim.

You have questions. We have answers.

Should I stop working if I am struggling to do my my job to due to psychological or physical symptoms?

You should stop working if your doctor recommends that you stop. Similarly, if you do not feel you are able to work or to complete your job duties, you should stop working and see your doctor. Sometimes clients push themselves to work despite their functional restrictions and limitations. Continuing to work when you are unwell may strain the relationship with the employer and/or aggravate your medical conditions. If you need help deciding when and if to stop working, contact us.

When should I apply for disability benefits?

You should apply for disability benefits as soon as you are not able to work or complete the duties of your job due to an illness or injury. Some insurance policies have a deadline within which you submit your claims forms. If you have missed the deadline for submitting a claim, you should still submit your claims forms, as soon as possible. In some cases, the insurance company may still consider your claim, despite its lateness and it is important that you contact us, right away.

How do I apply for disability benefits?

If you have coverage under a group disability plan through your employer or an association, you should start by contacting your employer/association to obtain the disability claims forms. If you have an individual or private disability insurance policy, you should contact the insurance company directly to obtain the forms. Your insurance broker might also be able to help you. You may also be able to download the forms from the insurance company website. There are usually two forms that will be required to apply for LTD: the Claimant’s/Member’s/Policyholder’s Statement (completed by you) and the Attending Physician’s Statement (completed by your doctor). With group insurance, the insurer will also ask your employer to complete a form (Employer’s Statement). With individual/private insurance, you may also be asked to provide details about your business and financial losses due to your disability. If you need help, contact us.

How can I get approved for disability benefits?

You should apply for LTD as soon as possible (even if you are still receiving Sick Leave, STD or EI Sickness benefits) and include as much information about your functional limitations and restrictions as possible. This includes providing detailed answers to questions on your claim form and ensuring your doctor provides detailed answers on their form, as well. We suggest you meet with your doctor prior to them completing the Physician’s Statement to ensure they includes all relevant information about your disability and to remind them to attach all supporting documentation such as test results, specialist consultations reports and any other records that support your claim. If you need help, contact us.

I do not have a diagnosis and the doctors do not know what the cause of my symptoms. Will my claim be denied?

Although a diagnosis is not a requirement under most disability policies, it is something that the insurance company will use to gain a better understanding of the severity of your symptoms and your functional limitations and restrictions. If you have an undiagnosed illness that is preventing you from working, it is important that you and your doctors continue to investigate the cause of your condition while also treating your symptoms. The insurance company should be focused on whether you are functionally able to work and not a specific diagnosis. If your benefits are denied because your illness has not been diagnosed, you should contact us right away.

What if my doctor is not supporting my disability claim.

It is important that your treating doctors and specialists support your claim for disability benefits if you are not able to work. If your doctor is not understanding the nature of your restrictions and limitations, you may be able to rely on your other doctors and specialists to complete forms and communicate with the insurer. In some cases, you may need to find a new doctor who will be more supportive. If your doctor has refused to make referrals to specialists or has refused to complete insurance forms or communicate with the insurer, you may want to consider contacting the Ontario College of Physicians and Surgeons to determine what your doctor’s obligations are in that respect. If your doctor is not supportive contact us to discuss how you will prove your claim.

There are long waitlists for specialists and/or I can’t afford treatment. How will that affect my disability claim?

Your disability insurance policy requires you to be receiving appropriate treatment as a condition of receiving ongoing benefits. The insurance company should be aware that many communities are under-serviced with respect to specialists and treatment providers (particularly for mental health claims). Also, if your extended health care benefits have been used up or your benefits have been terminated by your employer, you might not be able to afford ongoing treatment costs. In these cases, the insurance company should not be terminating your benefits due to a lack of appropriate treatment. If the insurer does deny or terminate benefits for these reasons, you should contact us right away.

How is my disability benefit calculated?

The monthly amount of your disability benefit is based on calculations in the insurance policy. Disability insurance is a form of income replacement and generally does not provide you with 100% of your lost earnings. Generally, your benefit will be based on a percentage of your pre-disability earnings or income. Many group policies have a benefit amount ranging from 50% to 75% and usually it is 66.7%. You should refer to your benefit booklet or policy or contact your insurance company, employer, union or broker to find out what your benefit amount will e. You may also want to determine whether the calculation is based on your net or gross pre-disability income and whether the benefit is taxable (your employer contributed to your premiums) or non-taxable (you paid the full premium for the benefit). Calculations under individual or business interruption policies may be more complicated. Contact us if you need help determining your benefit amount.

The Authorization the insurance company wants me to sign is very broad. Do I have to sign it?

You should be aware that when you complete your portion of the LTD claims forms and sign the form, you will be providing the insurance company with a broad authorization to collect and share your personal information. You should read the small print to ensure you are aware of what you are agreeing to provide access to. The insurance company will use your authorization to gather information from your treating health care providers in assessing your eligibility for disability benefits. Privacy laws stipulate that they can only request the information they need to complete the purpose for which the information is required. If you choose not to sign the authorization, your insurance company may threaten to deny your claim if it is unable to obtain the information it needs to assess your entitlement.

To find out more about your privacy and your rights when it comes to signing these authorizations, please contact us.

Will I lose my job if I go off on disability or if my disability claim is denied?

Your employer must abide by provincial and federal employment and human rights laws. These laws will determine how your employer responds to your absence. Employers normally do not terminate a person’s employment when they are disabled (whether disability claim has been approved or not). However, each case is different. For example, if a person has been off work for a significant period and is receiving disability benefits and it is unlikely that the person will be able to return for the foreseeable future, the employer may decide that the employment contract has been frustrated and end the relationship. If a person has not been approved for disability benefits and has not returned to work and has not provided any information about when or with what accommodations they will return to work, the employer may conclude the person has abandoned their job. Employers have a duty to accommodate persons with disabilities or explain why they are unable to accommodate the person, before terminating their employment. If your employer has terminated your employment and disability is a factor, contact us right away

Why was my disability claim denied?

There are many reasons why your disability claim may have been denied. The denial letter will state the basis for the denial. It may be that there was insufficient medical information to support that you are not able to work and that you are disabled. It may be that the insurance company finds you have not had “appropriate” treatment or that your treatment is not indicative of a severe condition. There may notes in your medical records that suggest that your condition is improving or that that you have the functional ability to complete the duties of your occupation. If you do not participate in the insurance company’s rehabilitation plan or if you do not do a gradual return to work proposed by the insurer, your claim could also be terminated. There may be many other reasons, such as surveillance, which may/may not be mentioned in the letter but which played a role in the denial. Contact us immediately upon receiving your denial letter.

Can my disability claim be denied based on a pre-existing condition?

Most disability policies have a pre-existing condition exclusion clause. The wording of the clause varies between policies, but typically a disability claim will be denied if you become disabled within 12 months of becoming insured under the policy, if your disability related to condition for which you sought treatment or consulted a doctor within the three month period prior to your coverage taking effect. This is an important exclusion to consider if you feel you might need to stop working due to disability and you are a new employee, not having disability coverage in place for a full year. It is important you contact us to review the exact wording of your policy to advise you how this clause might impact your LTD claim if you stop working within 12 months of having your LTD coverage.

What should I do if my disability claim has been denied or terminated?

If your disability claim has been denied, you have a time limits for appealing and suing. For example, in Ontario, you have two years to sue from when your clam was initially denied or when they stopped paying you. Your policy will also have a time limit for appealing. It is therefore important that you contact us immediately to determine whether to appeal the denial or to litigate. We will be able to tell you which option is best in your case. You should continue with your treatment and continue to see your doctors. If your employer contacts you, you should advise the employer that you are still disabled and you will be appealing or contacting a lawyer to dispute the denial of your claim. You should not return to work before you are medically ready or without medical clearance. Doing so may aggravate your condition and impact your relationship with your employer if you are not able to do your job.

Should I appeal the denial or termination of my disability claim?

If you have had a significant change or worsening in your condition since the claim was denied or if you have new medical records to support your claim, it may be worth appealing the denial. If you have provided all the relevant records and remain disabled, then it may not be worth your time or effort to appeal and litigation may be the better option. We suggest you contact us immediately if your LTD claim is denied. We can discuss your options and assist you with your appeal or in litigation.

When should I call a lawyer?

You should contact us when your LTD claim is denied and you are still not able to return to work. If you believe that your claim will soon be denied based on your communications with the insurance company, you can also contact us, in anticipation of the denial. The sooner we are involved, the sooner your dispute with the insurer will be resolved.

How do I support myself if my disability claim is denied or terminated?

There are government disability benefits that may be available to you if you are disabled. For example, you may be eligible for EI Sickness Benefits, CPP Disability Benefits, Ontario Disability Support Plan, Ontario Works. If your LTD claim is denied, you should contact us immediately, to ensure litigation starts right away and your claim is resolved as soon as possible. We can also provide you with information and guidance about other potential claims you may have such as employment, human rights, injury, etc.

Will I still have my extended health coverage while I am off on disability?

Your employer may or may not choose to continue to pay for or offer you to pay for your extended health benefits for you while you are disabled. They may pay the premiums or ask you to pay them in order for you to keep the coverage. If you cannot afford to pay the premiums, your coverage will stop and will not be reinstated until or if you return to work. You may also be entitled to extended health coverage under provincially funded plans like Trillium, depending on your financial need.  If your LTD claim has been denied and you are concerned about how to pay for treatment, contact us to discuss your options.

The insurance company is threatening to terminate my claim if I do not participate in their “rehab” plan but it is making my condition worse. What can I do?

The insurance company can require you to comply their rehabilitation program in an effort to return you to work. A rehabilitation plan may include therapies (such as physiotherapy or psychotherapy), job search assistance and a gradual return to work plan with or without accommodations. If you do not comply with the rehabilitation plan, the insurer may terminate your benefits. We encourage you to ensure that your treating doctors and specialists are consulted throughout any return to work planning. Should you or your doctors feel that the insurance company’s efforts are aggravating your condition or that you are not ready to return to work and that you should not participate in the program or stop your participation, you will require a detailed note or report from your doctor. If the insurance company then terminates your benefits on the basis of non-compliance with rehab, you should contact us right away.

The insurance company is forcing me to return to work before I am ready. What can I do?

If your employer contacts you, you should advise that you are still disabled and you will be appealing or contacting a lawyer to dispute the denial of your claim. You should not return to work prematurely or without medical clearance. Doing so may aggravate your condition and strain the employment relationship. If your LTD claim has been denied and you need help navigating your communications with your employer, contact us.

The insurance company wants me to do a “gradual return to work” and has said if I do not, my benefits will be terminated. What can I do?

If the insurer is pressuring you to return to work and threatening to terminate your benefits if you do not cooperate, you should contact us, immediately. Returning to work before you are medically able could aggravate your medical condition and/or strain your relationship with your employer.

The insurance company is asking for more information. I have given them everything. What do they want and what can I do?

If there is more information to support your claim, you should provide it. However, if you have provided all the relevant information available, you can ask that the insurance company contact your treatment providers directly to address any outstanding questions/concerns or provide any additional records they may have. If your claim is then denied based on insufficient medical information or for whatever reason, you should contact us right away to determine next steps (appeal or litigation).

How does the defintion of disability in my policy change after two years. What if I am unable to work beyond two years?

Under most group disability policies, the definition of “total disability” changes after two years. For the first two years of disability, you must be disabled from performing the essential duties of your own occupation (your job for any employer). After that, you must be disabled from performing the duties of any gainful occupation for which you are suited by way of your education, training and work experience. The definitions of disability vary from policy to policy. You should refer to your specific policy to find out the definition of disability you must satisfy for benefits. Often claims are denied at the two-year mark when it becomes more difficult for people to prove that they are totally disabled from any occupation. If your claim is denied at this point, you should contact us immediately.

The insurance company is sending me for a medical assessment. Should I be worried?

The insurance company has a number of “tools” it can use to assess claims. Sending you to an independent assessment is one. An insurance company will send a person for an assessment when it is not clear from the existing records whether the person is disabled. Sometimes the person has not seen an appropriate specialist or sometimes there is contradictory information in the records which requires clarification. It is important to understand that the doctor you are seeing as part of the assessment has been hired by the insurance company and will not be treating you on an ongoing basis. You are entitled to a copy of the doctor’s report (whether it be sent to your doctor or to you directly). If the report does not support your disability claim, contact us right away.

Will the insurance company do surveillance on me?

It is difficult to predict when or if an insurer will conduct surveillance. If the insurance company is not paying your claim at the moment, it will not conduct surveillance (unless you are in litigation). If your claim has been approved, the insurer, as part of its ongoing assessment of your claim may choose to order surveillance. Surveillance is done when an insurance company has questions about your credibility and functionality. They may have discovered some inconsistencies in the records or they may believe that you are more functional than you have told them told your doctors. Surveillance is not limited to claims based on physical conditions. Insurance companies will use surveillance to assess all types of disability claims including mental health-related claims and other invisible conditions. If you are concerned that the insurance company has used surveillance to deny your claim, contact us right away.

What can I do if I suspect that the insurance company is doing surveillance on me?

You should go about your normal day-to-day activities. You should be sure to provide accurate reporting of your activities to your doctors and to the insurance company. You do not want there to be any inconsistencies with respect to your functioning on surveillance and your reported functioning to your doctors and the insurance company. You can call the police if you feel threatened or uncomfortable. Police may speak to the investigator but if the surveillance is being conducted legally, police will not put a stop to it. The investigator may stop surveillance knowing he has been identified by you. If you find surveillance to be causing you stress, you should speak to your doctor about it and also contact the insurer and contact us if you need our help.

Is it legal for the insurance company to do surveillance on me?

Surveillance is legal so long as the insurance company and investigator are not in breach of privacy laws (PIPEDA). This means that the surveillance must be justified and there is no other means by which the insurance company could obtain the information other than by surveillance. Take some comfort in knowing that the investigator may not enter your home or peer through your windows or look over your fence. The investigator must be able to view you from public property. This means that they may take photos and video of you while you are on your property or in any public space. The investigator may follow you while you run errands or socialize or go to appointments, etc. They will also conduct online surveillance to gain information about your activities from what you post on social media or other platforms. If you are concerned about surveillance or if your LTD claim has been denied based on surveillance, contact us.

I am receiving disability benefits but I would like to try to return to work. What can I do?

If your condition has improved to the extent that you are able to attempt a return to work, you should discuss this with your doctor first. Your doctor may recommend accommodations and a gradual return starting with reduced hours. You may then wish to contact the insurance company. Often they will work with you and your employer and your doctor to transition you back to work. You may also want to reach out directly to your employer. If you are unsuccessful and go off work again due to the same or related disability within a set period of time (usually six months), your policy may have a Recurrent Disability provision which would allow for your benefits to resume without having to satisfy the waiting period, again. It is important to contact us to discuss this issue so that you do not compromise your rights unintentionally and so that we may review your policy to determine your rights.

What other benefits or sources of income could be available to me if I am disabled?

You may have access to a number of private and public income benefits, depending on a number of factors, including the severity of your condition, the cause of your illness or injury, your financial circumstances and the plans/policies under which you have coverage. The following is a list of sources of income, that may be available to you:

  • Short-Term Disability or Weekly Indemnity Benefits through a group insurance plan;
  • Long-Term Disability Benefits through a group plan or private/individual policy;
  • Business Interruption Insurance;
  • Disability Creditor Insurance (under your mortgage or credit cards);
  • Critical Illness Insurance;
  • Accidental (Death) or Dismemberment Insurance;
  • Workplace Safety Insurance Benefits (WSIB);
  • Employment Insurance Sickness Benefits (EI Sick);
  • Ontario Disability Support Plan (ODSP);
  • Ontario Works (OW);
  • Income Replacement Benefits (IRB’s);
  • Extended Health Care benefits;
  • Trillium (extended health benefits);
  • Canada Pension Plan Disability (CPP-D); and
  • Disability Pension (employer).

Should I apply for Canada Pension Plan Disability benefits?

At some point after being approved for disability benefits (usually around the two-year mark), the insurance company will require you to apply for CPP Disability (CPP-D) benefits. CPP-D benefits are an “offset” under most disability policies (but not all). This means that any amount paid to you by CPP-D will reduce your disability insurance benefit. The definition of disability under CPP-D is more difficult to satisfy than those under your disability insurance policy. If you do satisfy the definition and are approved, it may be more difficult for the insurance company to terminate your benefits. If you do not apply for CPP-D, some insurance policies allow the insurance company to reduce the disability benefit they are paying you by what you would have received from CPP-D, had you applied and been approved. It is therefore best to apply for CPP-D. If your LTD benefit is being reduced by CPP-D but you have not yet been approved for the benefit and perhaps not even applied, this is a serious financial situation for you and we suggest you contact us right away.