Legal Assistance

Appealing the denial of a long-term disability claim

The long-term disability benefits

The long-term disability benefits provider will decide whether to accept or reject your claim once you apply. Every insurance provider offers a procedure for claimants to challenge a refusal. Typically, an internal appeal is the first step, and civil lawsuit for breach of contract is the last.

Fortunately, the appeals process is essentially the same for all disability plans in Ontario.

Soon after applying for LTD benefits, you will receive a letter from your insurance provider suggesting a decision on your claim. Do not presume that the insurance company’s judgment is sound if your claim has been rejected or terminated for any reason. Their decision may be flawed for various reasons and should be challenged. You will typically have two options for challenging the insurance company’s decision.

File an appeal:

The first choice is to contact the insurance provider and file an internal or external appeal. You may appeal a decision three times depending on how the policy is written. However, you typically need to submit each appeal within 90 days of the decision.  It is important to remember that unless your doctor can provide significantly different medical information to support your claim, appealing the ruling is not the best course of action.

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    Start a lawsuit against the insurance provider:

    The other choice is to sue the insurance provider for breach of contract and wrongfully denying disability compensation payments. It is recommended to have legal counsel for the best possible outcome. Legal counsel will take much of the burden off your shoulders and allow you to focus on recovery.

    Things to Remember:

    • It’s crucial to continue participating in therapy, seeking out continuous care, and pursuing the best possible course of treatment for your health, even if your claim has been rejected or you believe it will soon be.
    • This is crucial for claims involving illnesses including fibromyalgia, chronic pain, chronic fatigue syndrome, and mental disorders. Maintaining regular doctor appointments and following through on your treatment is essential. It can be challenging to diagnose these conditions with objective testing, such as bloodwork or diagnostic imaging. By keeping regular appointments, your doctors can assess your limitations and restrictions and record the ongoing symptoms that keep you from working.
    • Insurance companies may reject claims for invisible illnesses if there is a lack of medical proof, a person has not received treatment, has not complied with treatment recommendations, or is not being treated by a qualified medical professional.

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