Long-term disability insurance is essentially a form of income replacement when you are unable to work. However, unlike OHIP or other universal coverages available to people living in Ontario, not everyone has long-term disability insurance. Additionally, not all long-term disability insurance pays out the same or has the same qualifying terms.
In many cases, but not all, people who work full-time are offered some form of long-term disability benefits through their employer. However, for those who are self-employed or work as independent contractors, it’s unlikely that you have long-term disability available to you. In those cases, you can take out private long-term disability insurance.
No one plans to get sick and be unable to work, however, sometimes the worst happens. That’s why it’s so critical that you have suitable long-term disability benefits available to help you.
Understanding Long-Term Disability Insurance
As stated above, many employers provide some type of long-term disability benefits plan. Some do not. Long-term benefits are intended to pay someone up to 60% of their gross salary (many have monthly limits) for the duration that they cannot work. It is important to know that there are many conditions that must be met for you to qualify for long-term disability benefits. It’s not enough to just decide that you cannot work. Further down, we will go over what qualifications need to be met to get long-term disability.
Once you have qualified for long-term disability benefits you will receive these benefits for as long as your insurer agrees that you are unable to work. You will receive periodic payments until you are either able to go back to work or as long as your benefits are valid. Many disability benefits will pay until you reach the age of 65. However, as stated above, all plans are different so it’s very important that you understand the conditions of your own plan.
There are many reasons you may find yourself unable to work. This includes:
- Serious injuries or accidents causing lasting damage
- Serious illnesses such as cancer, strokes, or heart attacks
- Chronic pain or other invisible illnesses
- Depression or other mental health disorders
Long-Term Disability Insurance Isn’t Paid Out Immediately
Long-term disability insurance is usually paid out once you have exhausted other unemployment insurance options, such as:
- Employment Insurance (EI)
- Short-term disability insurance benefits
- Sick leave benefits from your job
Once you have decided that you’re unable to work and have completed the necessary applications, there is usually a 90-to-120-day waiting period before your benefits come into effect. This period is usually called the qualifying, waiting, or elimination period.
How To Apply For Long-Term Disability Benefits
To get the form, you must first reach out to your insurance provider. They will provide you with the form that needs to be filled out by a medical professional. It’s important to understand that the form must be filled out in a certain way for your application to be approved. Many doctors don’t have a lot of experience with these forms, so speaking with a lawyer ahead of time can be very helpful. An experienced personal injury lawyer will be able to guide you in the right direction, making sure you know what information needs to be on the form and what needs to be submitted alongside the form.
This form must immediately meet the contractual obligations of your long-term disability insurance.
If these forms aren’t filled out correctly the first time, your claim may be denied, and you will need to restart the process from the beginning. To help your chances of being approved, it’s important that your doctor or other medical professional understands exactly what your symptoms are and exactly why you are unable to work.
Once your claim has been denied, reapplying can take a very long time. In many cases, those relying on disability benefits cannot afford to wait. That’s why working with a personal injury lawyer from the beginning can help ensure approval the first time around, getting you the money you need much quicker.
It’s important to note that you must continue to work with a doctor or medical professional on an ongoing basis once you’ve been approved to continue receiving long-term disability.
Long-Term Disability Benefits Are Also Available For Depression And Other Mental Health Disorders
Canada recognizes mental health disorders such as PTSD, serious depression, severe OCD, and more as disabilities under long-term disability insurance. The diagnosis alone won’t be enough to qualify you for long-term benefits, however. You will need to be able to prove that your mental health condition is severe enough to keep you from working. Insurers will scrutinize how your symptoms affect your work, how hard you tried to keep working, the severity of your symptoms, and your medical treatment plan both currently and in the future.
How To Qualify For Long-Term Disability Insurance
You will need proper medical documentation that proves your mental, physical, or psychological ailments. Essentially, an inability to work must be supported by the physicians looking after you.
You will qualify for long-term disability if you cannot perform the duties of your employment. It does not matter if you can perform other jobs, as long as you cannot perform the duties of your job. After 24 months, there is a change in the disability definition for many policies. However, limitation periods vary per policy or contract and can sometimes be as little as six months. The definition changes from “own occupation” to “any occupation” and if you qualify, the benefits will be paid until the age of 65. Bear in mind, the definition of “disability” differs between insurance companies. In some cases, it can differ between insurance plans from the same company too.
What Happens If My Long-Term Disability Benefits Are Denied?
Firstly, when individuals are denied long-term disability insurance, it is highly subjective. Decisions will be based on the intricate wording of insurance policies and the interpretation of key terms. Long-term disability policies are purposefully written with highly complex legal language and provisions that are unclear to everyday individuals. This is intentional, so you are put off from making a claim.
These are some of the most common things individuals hear when long-term disability applications are denied.
“There is insufficient medical documentation”
“Unfortunately, you failed to submit your application on time”
“You aren’t experiencing ‘total disability’”
“There are alternative occupations you can pursue right now”
“We have been running surveillance on you”
“There is incorrect or missing information in your application”
“Our medical team doesn’t think you’re disabled”
“There is conflicting information between your doctor’s medical reports and our medical team’s reports”
Appealing Your Long-Term Disability Insurance Denial
The process for completing a long-term disability denial appeal is as follows:
1. Take note of the deadline for appeal
When individuals experience long-term disability claim denials, they often receive a letter stating that they can appeal the decision. Remember, you simply cannot miss the deadline to appeal. Typically, the deadline for appeal will be included in the final few paragraphs of the letter.
2. Remember you have employment rights
After your claim is denied, insurance companies also send a letter to your employer. This letter will state that you’re unable to work and don’t qualify for long-term disability. Your employer will be suspicious, but you simply need to inform them that you disagree and are appealing their decision. Circumstances vary but reasonable employers will still grant you unpaid sick leave during the appeals process. Others may demand you return.
3. Prepare all necessary documents for your appeal
A successful long-term disability appeal requires many documents. These include a denial letter from your claim representative, the manual that describes your long-term disability benefits, and a copy of your doctor’s medical file. The latter document provides explicit proof of your claim. Other important documents include the insurance company’s claim file if your claim was over six months ago, and a copy of your union’s collective agreement if applicable.
4. Research other benefits you could be entitled to
Unfortunately, long-term disability appeals take time. During that time, you’ll need alternative sources of income and support. Take time to research whether you qualify for Employment Insurance (EI) or other forms of disability benefit.
5. Study your denial letter and finalize documents for your appeal
Insurance companies must give a reason to deny long-term disability. The best-case scenario is when your denial letter lists specific documents that are necessary for your appeal. Often, missing medical information creates the biggest problems. Missing medical information will be written technically to put you off but remember, you can still consult with your family doctor to clarify your diagnosis, prognosis, treatment plan, and so on. In instances where the insurance company’s reasons aren’t so clear, consulting with an Ottawa long-term disability lawyer like MG Law can help.
6. Finalize and send your appeal letter
This is the stressful part, as clients want to ensure they’ve prepared the strongest appeal possible. While your letter is important, it’s actually your medical records that hold the weight in reversing the insurance company’s denial of your claim. In basic terms, your appeal letter must simply state that you are requesting an appeal; you’re attaching documents in support of your appeal, and you’re taking action before the insurance company’s stated deadline. After submitting your appeal letter, you’ll typically get a response within 30 to 60 days.
Long-Term Disability Appeal Failed? What Next?
If you’ve exhausted long-term disability appeals, the next step is an appeal by lawsuit. Firstly, it’s important to be aware of timeframes. For lawsuits against insurance companies, there is a strict 2-year limitation period that begins from the moment your claim is denied.
Ultimately, insurers don’t have to pay your claim or worry about being sued in court when you miss this strict time limit. In short, the clock starts ticking as soon as your claim is denied. All in all, you must make the decision whether to spend time with the appeals process or alternatively, hire a long-term disability denial lawyer to start an effective defence of your claim.
MG Law Can Help You File A Long-Term Disability Appeal
When an insurance company wrongfully denies your claim, you need to seek competent legal advice as soon as possible. To move forward, your best bet is to hire experienced long-term disability denial lawyers like MG Law. Not only will we review your rights and remedies, but we’ll also work with you every step of the way to ensure your benefits are reinstated.
Since 2009, we’ve proudly served clients based in Ottawa and beyond. Long-term disability insurance is our passion, and we care about getting the best outcomes for our clients. We believe everybody wants to work. That’s why our team will work tirelessly to help you make sense of complicated legal language while adhering to all deadlines and processes required to get you the maximum benefits owed to you and your family.
Our team is ready to help you move forward. Call (613) 730-8460 today for your free consultation.
