Why Disability Benefits are Denied in Ontario?

What are some of the reasons that your long-term disability benefits can be denied or cut-off?

Disability claims adjusters routinely deny disability applications on behalf of disability insurance companies for countless reasons, some of which are legitimate and many more that are illegitimate. Understanding some of the reasons as to why disability claims are denied can help you prepare your best possible case. Here are some of the more common reasons why our disability lawyers see LTD claims denied:

Social Media and Video Surveillance – disability benefits can be denied and a repayment can be demanded if the insurer’s fraud department obtains surveillance of you performing activities which may be inconsistent with your chronic illness or injury. Often times however, surveillance is unhelpful to the insurer because everyone has good days and bad days.  A cancer victim or a claimant with mental illness may have days where he or she feels better and wants to enjoy going to the beach – but it does not mean that that person is capable of working and does not suffer a total disability.  Insurance companies still can deny your claim if what you portray contradicts the evidence you provided to them.

Lack of medical evidence –  during the disability claims process, the claimant must provide medical records that prove the are too sick, ill or hurt to work. Your long-term disability benefits can be denied if you do not provide the insurer with the medical evidence it needs to properly adjudicate your claim.  Courts have repeatedly said that insurance companies “are not investigators” – so if your disability carriers asks you for additional medical evidence to support your disability claim, try your best to jump through hoops to provide it to them.  Remember – the onus is on you, the claimant, to prove your disability.

Missing medical records – Long-term disability claims are routinely denied because the claimant failed to provide sufficient medical evidence to support their application.  At times, your family doctor’s clinical notes may be missing return consultation notes, operative notes or specialist notes that may trigger the insurance company to request further records.  Make sure to be diligent upon applying for long-term disability benefits and ensure that you provide as much of your clinical file as possible.

You are not following a treatment plan or consistent medical treatment – did you know that most, if not all disability policies mandate that you participate in a continuous treatment plan?  Treatment can be therapy, rehab, seeing a psychologist, seeing your doctor, participating in local hospital mental health programs, being an outpatient, ect. It’s important that you try to mitigate your losses by always trying to make yourself better. Regular care is a must.   If you have received too little treatment you will not be able to successfully prove your claim. You cannot establish that your condition is serious enough for you to be able to work if you are receiving hardly any treatment for your condition.

Failure to meet the definition of total disability – your policy, like all disability policies, contains a definition of “total disability”. Total disability is normally defined for the first two years as a claimant being unable to perform the substantial duties of his or her own employment. After receiving 24 months of disability – claimants then face a COD or “change of definition”, where your policy’s definition of total disability changes from not being able to do your “own job” to being unable to work at “any job” in which you are reasonably suited by way of your education, training and experience.  It’s at this point that many insurance companies argue that claimants fail to meet the more onerous definition of disability.

Compulsory or Independent Medical Exams – sometimes insurance companies will provide your medical records to their insurance company doctor for a paper review.  That doctor could review your file, disagree with your doctor, and no doubt determine that you are not disabled. The bigger picture, however, is that in nearly 100% of the cases the doctors employed by the insurance companies do not have your full and complete clinic file, they have not met you and they more likely than not practice in an areas of specialty that has nothing to do with your injury or chronic illness.

Missed deadlines – if you have been denied disability it’s important that you understand that there are limitations to when you can appeal and/or sue the disability carrier for wrongfully denied benefits. Contact a disability lawyer sooner rather than later.

Your adjuster demands objective tests to establish the existence of a condition for which there are no objective tests – it is not uncommon for claims adjudicators to argue that a certain diagnosis lacks objectivity, particularly when compared with diagnoses in other medical specialties.  Psychiatric diagnoses are particularly difficult in some cases.  For example, people suffering from serious depression, bi-polar disorder, borderline personality disorder and other such disorders often make insurance companies concerned (although most disability claims are mental illness related). Clinically, there is no blood or other biological test, x-ray, laboratory or other testing which can ascertain the presence or absence of a mental illness, as there is for most bodily diseases. Sadly, some adjusters do not understand that mental illness is terribly life-altering for some people and chose to deny.

Your policy has excluded conditions –  Your long term disability policy may specifically exclude coverage for certain clinical conditions. Often times we see exclusions related to alcohol or drugs.  Moreover, certain medical conditions may be limited to 12 months of benefits if you are insured under a group policy.  In practice, most long-term disability insurance policies define the parameters as to what can be classified as a pre-existing condition.

Have you been denied your long-term disability benefits? We can help

Lalande Personal Injury Lawyers understand that when claimants are denied disability insurance, they are often put in a terrible position emotionally….and financially. If you believe you have been wrongfully denied or cut-off your long-term disability benefits, fill in a contact form or call us today at 905-333-8888. We can offer guidance, insight, knowledge and legal representation related to your long-term disability benefits.  We would be happy to offer compassionate advice and help you understand your rights – since most disabled employees cannot fight for benefits on their own. Contact us to schedule a free, no obligation consultation today.