LTD Denied – What Are My Options? Should I Appeal or Should I Sue the Insurance Company?

If you applied for LTD benefits and your insurance company denied your claim or if you were receiving LTD benefits and your insurance company terminated or cut-off your benefits, but you are still unable to return to work, then you may be wondering what options are available to you to fight the denial or termination of your benefits.

You have two options: 1) Appeal the decision to the insurance company or 2) start a Court Action against the insurance company.

The option you choose will depend, to a large extent, on why the insurance company denied or terminated your claim and what evidence is available or could be obtained to support either an Appeal or a Court Action.

Time is also a factor. If you are approaching two years since your insurance company stopped paying you or denied your claim, you may need to act quickly, to preserve your right to bring a Court Action.

To decide which path to choose, it is important to first understand each of these two options.

1. What is an LTD Appeal to the Insurance Company?

Your insurance company probably offered you the option to appeal the denial or termination of your benefits. The letter they sent to you denying your claim, likely set out a list of documents that you would need you or your doctor to submit, in order for you to appeal the decision.

The insurance company will review the new documents you submit and determine whether the new information you provided is sufficient to change its mind and reinstate or approve your benefits. If your appeal is successful, your benefits will be paid from when they stopped paying you and then you will continue to receive benefits on a monthly basis, so long as you continue to meet the definition of disability and other conditions in the policy. They may cut-off your benefits again, down the road.

You may or may not decide you need help from a lawyer with your appeal. If your appeal is complicated or if dealing with the insurance company has become a damaging source of stress and anxiety for you, Mulqueen Disability Law can help you with your appeal. However, you may be able to appeal the decision on your own with or without the guidance of a disability lawyer. In either case, Mulqueen Disability Law can provide various levels of assistance with your appeal, depending on your individual needs.

2. What is a Court Action for an LTD Benefit Dispute?

Once your insurance company denies or LTD claim or stops paying your LTD benefits, you can bring a Court Action (lawsuit) against the insurance company. There is no law or requirement in most insurance policies, that requires you to first go through the insurance company’s appeal process. Not appealing the decision will not be held against you in your Court Action.

In a Court Action, your disability lawyer will make various claims against your insurance company, including a claim for the payment of your LTD benefits. (See our website for more information about the Steps in an LTD Lawsuit.) In the end, most LTD Court Actions will resolve in one of three ways: 1) Payment of a lump sum settlement of all past and future claims; 2) Reinstatement of your LTD benefits; or 3) Judgement at Trial. A disability lawyer will be able to provide you with the pros and cons of each of these three types of resolutions to determine which outcome is best for you and what you can expect from your LTD Court Action.

Remember that in Ontario, the Limitations Act provides for a two-year limitation period within which to start a Court Action against the insurance company for LTD benefits. If you missed this deadline, you should still contact a disability lawyer to determine whether there may be a way around the missed limitation period.

If you are unionized, you may or may not be able to bring a Court Action. You may be required to grieve the LTD decision and a Court might not have jurisdiction over your dispute. Jurisdiction will depend on the wording of your collective agreement. It is best to speak to a disability lawyer and your union representative about your rights to dispute the denial of your LTD benefits by way of Court Action. An experienced disability lawyer will be able to review your collective agreement to determine whether the Court has jurisdiction to deal with your LTD dispute. Keep in mind there is probably a time limitation for grieving the denial or termination of your claim under your collective agreement.

If you are a Teacher in Ontario, you do not need to appeal a denial/termination of your LTD benefits. Mulqueen Disability Law has decades of experience representing Teachers in their OTIP/Manulife LTD disputes. Contact us for a free consultation to discuss your options and the implications for your pension and other issues unique to OTIP/Manulife LTD claims.

Should I Appeal or Bring a Court Action?

There are a few important factors to consider when deciding whether to appeal to the insurance company or start a Court Action. These factors include:

1) The reason or basis for the insurance company’s decision to deny or terminate your LTD benefits;

2) Whether there is evidence available or obtainable to support your claim;

3) How long ago your claim was denied/terminated.

We will explore each of these three factors to help you determine which path is right for you to take in your fight for your LTD benefits.

Why Was My LTD Claim Denied or Terminated?

LTD benefits are available to you either through a private insurance policy or through a group insurance policy (provided by virtue of your employment or membership in an organization) . The policy is a contract. As a contract of insurance, the policy sets out various terms and conditions you must satisfy to be eligible for benefits. The insurance company assesses claims based on these terms and conditions. If it finds that you do not satisfy the terms and conditions in the policy, it can use those terms and conditions to deny/terminate your LTD claim.

Some of the most common reasons LTD benefits are denied or terminated include:

• Not eligible for the LTD coverage under the policy;
• Not totally disabled from your own or any occupation;
• Not receiving appropriate treatment;
• Failing to participate in the insurance company’s rehabilitation program;
• Insufficient medical information to support your claim; and
• Disability due to a pre-existing condition.

Often your decision to appeal or bring a Court Action will depend on the reason for the denial or termination. Sometimes it makes sense to appeal, while other times, it may be best to proceed directly to a lawyer to start a Court Action. A review of some of the most common types of denials/terminations will help you determine which way to proceed.

LTD Denials Based on a Lack of Insurance Coverage

Before the insurance company even begins to consider whether you are disabled and entitled to LTD benefits, it will want to confirm that you have LTD coverage under the insurance policy. To do this, the insurance company will want to confirm details such as, when you were first enrolled in the insurance plan; whether premiums have been paid for you; whether you were actively at work when your insurance took effect; and what your employment status was right before you became disabled.

Sometimes LTD benefits are denied, at this early stage, if the insurance company determines that you are not eligible to even apply for LTD benefits because you did not have the insurance coverage when you became disabled. This may be because your employment was terminated on the date you became disabled or on a date before you became disabled. Eligibility might also be an issue if your employer failed to properly enroll you in the insurance plan or if you did not pay premiums.

At this point, you may think that there is no point in appealing the insurance company’s decision. However, in many cases, this type of denial can be disputed, which will force the insurance company to reconsider your coverage and assess your LTD claim.

LTD Denials or Terminations Based on Lack of Medical Evidence

More often, the insurance company will deny or terminate your LTD benefits if they determine that the medical information you have provided to them is not sufficient to support “Total Disability” (often defined as being unable to perform the essential duties of your own or any occupation due to an illness or injury).

If this is the reason you have been given, you may be able to go back to your treatment providers and ask for more or updated information to support your appeal. If you have already provided everything available, then you may need to proceed directly with a Court Action. A disability lawyer will be able to use the information you have already provided, obtain very specific new information and frame everything in a way that is persuasive to the insurance company, resulting in a resolution of your claim.

LTD Denials or Terminations Based on Other Terms in the Policy

If your claim was denied or terminated for some other reason, such as not having appropriate treatment (or not having treatment that would suggest a severe condition); non-compliance with the insurance company’s rehabilitation program; having a disabling condition that results from a pre-existing medical condition; or some other reason, your case may be more complicated than you think. In these cases, providing some updated medical records as part of your appeal, may not be enough to change the insurance company’s decision and a Court Action may be your only option.

Appeal VS Court Action – The Final Verdict

Generally, if you still have time to bring a Court Action (in other words, you are not close to the two-year limitation period), and you have or you can get new and persuasive medical support for your disability claim, then appealing the insurance company’s decision may be the right way to go.

You may be able to do the appeal on your own or you may choose to hire a lawyer to help you with your appeal. This could save you significant time and money in legal fees, if the insurance company then approves your claim on appeal.

The risk in appealing is that appeals may take a long time (drawing you closer to or even beyond the two-year limitation period for Court Actions). Furthermore, in our experience, appeals do not normally result in the insurance company reversing its decision.

It is best to contact a disability lawyer to determine whether an appeal is the best option for you. Remember, if your appeal is not successful, you can then proceed with a Court Action.

However, if you have a complicated LTD case, a Court Action will probably be the better, if not only way to persuade the insurance company that you are entitled to LTD benefits. Complicated cases often include cases where:

• You have already provided all available information about your disability to the insurance company;
• You have already appealed at least once, if not more than once and you the insurance company is upholding the denial or termination;
• Your treating doctors and specialists are not cooperative or not supportive of your disability claim;
• Your coverage is at issue (the insurance company says you are not covered under the policy);
• You are suffering from an “invisible condition”, meaning there are no definitive tests to diagnose you or objectively measure the severity of your symptoms, such as:
  • Fibromyalgia
  • Chronic pain syndrome
  • Chronic fatigue syndrome
  • Multiple-chemical sensitivities
  • Post-concussive syndrome
  • Psychological conditions, including anxiety and depression
  • Undiagnosed condition
• You have had difficulty getting “appropriate” treatment for various reasons (such as, a lack of available treatment providers, an aversion to prescription medication, lack of money to pay for treatment, treatment from non-physicians, no referrals from your family doctor, no treatment has been helpful for your condition or none exists, etc.)
• The insurance company says that your disabling condition is “work-related” or “workplace specific”;
• You were forced to participate in a rehabilitation program or forced to attempt to return to work and you refused or your were not successful;
• The insurance company says you are disabled from a pre-existing medical condition
• The insurance company says you can do “any occupation” and lists some jobs they say you can do;
• The insurance company used surveillance to terminate your claim; or
• The Limitation Period for starting a Court Action (two years) is fast approaching or has already passed.

Often it may seem obvious to you and to your doctors that you are Totally Disabled and entitled to LTD benefits. However, insurance companies may see your claim very differently and completely disagree. You may actually have a more complicated case than you and your doctors believe.

Whether you decide to roll the dice and submit an appeal or proceed directly with a Court Action, it is important to contact a disability lawyer as soon as your claim has been denied or terminated.

If your LTD claim has been denied or terminated for any reason and you are considering whether to appeal the decision on your own or to retain a lawyer to help you with your appeal or to bring a Court Action, we encourage you to contact Mulqueen Disability Law for a free consultation. We will review your case with you, provide you with information and our thoughts about your case and help you decide whether to appeal or sue the insurance company.

We offer various levels of legal assistance for appealing your LTD denial, depending on your individual needs. If a Court Action is the better option for you, suing insurance companies for our disabled clients is what we do. We have over 50 years litigating LTD denials/terminations. We are a proudly women-led law firm focused on LTD litigation and helping our clients resolve their LTD disputes through our compassion, experience and dedication.LT

Contact Us To Discuss Your LTD Claim

If you would like to discuss your Long-Term Disability claim with an experienced disability lawyer, Mulqueen Disability Law LLP are experienced disability lawyers dedicated exclusively to the practice of disability insurance litigation. We have represented disabled clients in various professions against all major life/health insurance companies in Canada. We would be happy to provide you with a free consultation.

The preceding is not intended to be legal advice. This blog is made available for educational purposes only as well as to give you general information and a general understanding of the law, not to provide specific legal advice. By using this blog, you understand that there is no solicitor client relationship between you and the blog publisher. The blog should not be used as a substitute for competent legal advice from a licensed lawyer in your jurisdiction. If your disability claim has been denied and you require legal advice, contact a lawyer specializing in disability law.