Long-term disability benefits are intended to provide financial security for individuals who cannot work for an extended period due to disability. However, obtaining long-term disability benefits in Ontario can be an arduous journey fraught with complexities and obstacles. Navigating the intricate web of regulations and criteria established by insurance providers adds another challenge to an already daunting process. Despite the genuine need for support due to illness or injury, many individuals have their claims denied, leaving them with questions and financial strain.

Understanding the common reasons behind these denials can help those seeking long-term disability benefits. From insufficient medical evidence to administrative errors, this blog explores prevailing factors that often lead to LTD denials in Ontario.

Common Reasons for Denial

When it comes to initial applications for long-term disability benefits, understanding the common reasons for denials can help you better prepare your claim and increase your chance of success. Addressing and mitigating these reasons on initial applications requires careful preparation and attention to detail. Some common reasons for long-term disability claim denials are explored below.

Failure to Meet the Policy Definition of “Disability”

Each long-term disability insurance policy will contain a definition of “disability,” and to be eligible for long-term disability benefits, you must meet this definition. If your disability does not fit this definition, your claim may be denied. Therefore, it is essential to ensure that your claim illustrates how your disability satisfies the prescribed definition.

Missed Deadlines or Incomplete Documents

Insurance companies impose strict deadlines on filing claims or an appeal of a denial. As such, missing a deadline or submitting an incomplete or inaccurate application can result in the insurer denying your claim. Applicants must ensure they know and adhere to all deadlines to confirm their documents are filed on time. You must also ensure that your documents are filled out completely and error-free.

Pre-Existing Medical Conditions

Before submitting a claim, it is vital to review your long-term disability insurance policy and be aware of any clauses that may exclude benefit coverage for disabilities relating to a pre-existing condition. If your insurer believes your disability is derived from a condition that existed before your long-term disability coverage began, this may be used as grounds for denial. Therefore, it is essential to review your long-term disability policy to determine whether any exclusion clauses apply to your circumstances. It is also important to provide supporting evidence alongside your claim to establish that your disability is not a result of a pre-existing condition.

Lack of Sufficient Medical Evidence

An insurance company may deny your claim if it is not accompanied by sufficient medical evidence. This can be particularly prevalent with certain invisible disabilities and conditions, including mental illness or chronic pain, as insurers may not believe that what you are dealing with constitutes a disability for long-term disability benefits. Extensive medical records, including reports and expert opinions, are evaluated by insurers to validate your disability and your claim for benefits. However, if your application lacks comprehensive and supporting medical evidence or if your medical records do not explicitly describe the impact of your disability on your ability to work, your claim may be denied. For these reasons, it is important to speak with your medical providers and ensure your records accurately describe your disability and the corresponding impacts it has on your life.

Non-Compliance With Medical Treatment Plans

Your long-term disability insurer may deny your claim due to your failure to comply with medical advice or attend an independent medical examination (also referred to as an “IME”) at the insurance company’s request. Insurance companies may view such refusals or non-compliance as an attempt to avoid working and can use this as grounds for denial.

What to Do if Your Claim Is Denied?

It is not uncommon for insurance companies to deny an application for long-term disability benefits. In many cases, applicants feel their claim has been rejected for unfair reasons and choose to appeal the insurance company’s denial. If your claim has been denied, it is essential to know that you are not alone.

Understanding why your long-term disability claim was denied can be challenging to navigate. However, you can maximize your chances of success by seeking proactive legal advice. Whether you are seeking assistance with an application, appeal, negotiations, or require representation at trial, a skilled lawyer can review your denial letter and help you determine whether there is a legal basis for an appeal. If there are grounds for an appeal, a disability lawyer can help you collect and present updated medical evidence and persuasive arguments to your insurer in support of your initial claim. They will also be able to communicate with the insurance company on your behalf, along with your medical care providers, to allow you to focus on your health.

Contact Mulqueen Disability Law in Markham for Trusted Guidance on Appealing a Long-Term Disability Claim Denial

The skilled disability law team, led by Courtney Mulqueen, at Mulqueen Disability Law in Markham helps clients navigate the unknowns related to long-term disability claims, denials, appeals and litigation. When a claim is unfairly denied for any reason, it is vital to understand your rights and options for LTD litigation and appeals. To speak with a member of our team regarding your long-term disability denial, contact us online or call us at 416-900-0368 (or toll-free at 833-363-3LAW [3529]).