How to file and win a long term disability claim

If you are unable to work due to illness or injury, you may be entitled to long term disability (LTD) benefits. Many employers provide their employees with long term disability coverage through a group benefits plan.  Some professionals and self employed people will obtain a private policy of insurance that provides income protection coverage.  This blog will cover two topics:

  • How to claim long term disability benefits
  • How to increase your chances of having your claim approved

 

How To File A Long Term Disability Claim

Filing a claim for long term disability benefits is relatively straightforward.  Simply obtain the forms, complete them, and submit to the insurer. 

For group policies, there are typically three documents that must be completed and submitted: an attending physician’s statement, which is completed by your family doctor; an employer’s statement, to be completed by your employer; and a plan member’s statement, that you complete.

Filing a claim under an individual policy is similar, but without the employer’s statement.

The LTD insurer will then review the forms and likely arrange a telephone interview.  If everything goes well, your claim will be approved and will continue to be paid for so long as you meet the test of disability and meet the other policy requirements, such as being under appropriate treatment.

Unfortunately, many claims that should be approved are denied, either at the initial application stage, or at some later point.  Some of these claims may have been approved had they been submitted differently.  

 

How To Have Your Long Term Disability Claim Approved

There are several things you can do to increase the chances of having your long term disability claim approved, some of which are covered here.

 

Do Your Research

First, it is important to obtain a copy of the policy, or at least the benefit booklet, and preferably both. These documents will outline the test of disability, what you are entitled to if the claim is approved, timelines, and exclusions. 

Keep in mind the benefit booklet is only a summary of the policy. The actual policy will contain much more detail, and can be difficult to understand.  It will likely contain sections that address pre-existing exclusions, exceptions to exclusions, all source maximums, direct offsets, and indirect offsets.  These can be quite technical. Consider seeking help from a long term disability lawyer.

 

Be Timely

Often the policy will require that you notify the insurer within 90 days of the date benefits are to begin. Different policies have different time limits, but there is really no reason to delay applying.  If you are off work with the support of your treatment providers, and anticipate being off work beyond the start date of long term disability benefits, you should submit the claim sooner rather than later. 

If you are outside the time limit to apply, you may still be entitled to benefits based on the legal doctrine of relief from forfeiture, which is beyond the scope of this blog post. Contact a long term disability lawyer for more information about this legal remedy.   But if you wait too long, the applicable limitation period could be an absolute bar to your claim.  Again, best to seek legal advice before applying if a long time has passed since the onset of disability.

 

Complete The Forms Accurately And Truthfully

Be sure to carefully read any form you are required to fill out before you complete it.   Sometimes claims are denied because of mistakes that could have easily been avoided.

It is also extremely important to be completely honest and candid when providing information to the disability insurer.  Insurance claims require you (and the insurer) to act with the utmost good faith.  Any exaggerations or misstatements could result in claim denial.

 

Focus On Function

When describing your illness or injury, the LTD insurer will be more concerned with your functional restrictions and limitations than the diagnosis.  Of course diagnosis is important, but the insurer needs to understand why you cannot work. Be specific about what prevents you from performing your job duties.  For example, if your claim is related to mental health, don’t simply state “I am too anxious and depressed to work”.  Instead, focus on things like impaired focus, inability to multitask, avoiding stressful situations, impaired memory, specific side effects of medication, etcetera.

There is often only a tiny box on the application form to describe your symptoms. Feel free to include additional pages, but keep it concise and to the point.

 

Ask Your Doctor To Provide Medical Records

The attending physician’s statement often does not instruct your doctor to include medical records.  However, if your doctor is willing to, ask him or her to include the relevant clinical notes and records.  The LTD insurer will probably ask for these at a later date anyway, so may as well provide them early.

 

Be Careful With Workplace Issues

Many claims are denied because of workplace issues.  From the insurance company’s perspective, disability benefits only provide coverage for illnesses and injuries, not financial support while avoiding a toxic work environment.  However, legitimate medical issues that may have been caused or contributed to by the workplace can trigger legitimate and disabling medical issues.  When applying for long term disability benefits, you should therefore focus on your medical restrictions and limitations, not specific workplace issues.  That said, you must be honest and truthful with the insurer.   

 

Be Careful With Pre-existing Conditions

When an insurance company issues a group policy that covers many employees, the LTD insurer does not have the opportunity to conduct individual underwiring of each person now insured.  To avoid the potential enormous cost of someone with serious medical issues working just a few days or weeks, then claiming long term disability benefits for many years, most group policies contain a pre-existing exclusion.

However, this does not mean all pre-existing conditions are not covered.  The exclusion usually has several exceptions.  Typically, the pre-existing exclusion does not apply if you do not have any signs, symptoms, or treatment for the pre-existing condition before or after a specific number of days or weeks or months from the date coverage began.  The pre-existing exclusion also usually does not apply if you have been continuously covered for at least one year, and the date of disability occurs after at least one year of coverage.  

If your disability relates directly or indirectly to a pre-existing condition, you should do your best to continue working for at least one year since the date of coverage, or whatever time period is required for the exception to the exclusion to apply. You should also be very careful when describing the pre-existing condition.  Again, this is an area where consulting a long term disability lawyer before submitting your claim is very important.   

 

The Telephone Interview

Most LTD insurers will require a telephone interview after the forms are submitted.  It is important to be honest and truthful during this call.  It will probably be recorded, and any inconsistencies could lead to problems. 

 

Have A Long Term Disability Lawyer Review Your Application Before Submitting It

This blog only scratches the surface of issues that can arise when applying for long term disability benefits.  Your claim is more likely to be approved if you consult with a long term disability lawyer first.  Most LTD lawyers will agree to do so for a flat fee or an hourly rate. Michael Jordan is an experienced LTD lawyer who will review your application for free. If the claim is approved, you no longer require any legal assistance.  If the claim is denied, Michael can guide you through the process of an appeal or lawsuit, again without fee or obligation. 

 

Michael Jordan - Long Term Disability Lawyer in Ontario

About The Author

Michael Jordan is a long term disability lawyer with more than 17 years experience litigating all types of insurance claims.  He is a founding partner of the Bay Street firm Jordan Honickman Barristers.   Michael represents clients across all of Ontario, with satellite offices in Ottawa and London.

Email: mjordan@jhbarristers.com

Direct Cell: 416-460-6823

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Michael Jordan
Jordan Honickman Barristers

Direct Cell: 416-460-6823
Email: mjordan@jhbarristers.com

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