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When you receive a denial letter from your insurance company, you will probably be offered an opportunity to use the insurer’s appeal process. You may be required to submit an appeal of the insurer’s initial decision but this is usually not a required step. It is important to seek advice from a long term disability lawyer about whether an appeal is necessary. It is possible that the best path is to pursue legal action and sue the insurance company.
The insurance company will usually provide you with a period of time (often 30 days) to submit medical documentation in support of an appeal in order to request a reconsideration decision. The insurer will usually take approximately 4 to 6 weeks to make a decision. If the appeal decision does not result in a decision to pay your benefits, you may be offered a second level of appeal. This further reconsideration could take another period of 4 to 6 weeks.
Unfortunately, most LTD appeals are unsuccessful. If you have no new medical documentation to support your appeal, the insurer will likely deny your appeal. If you are not required to submit an appeal by your insurance policy, you should consider whether an appeal will simply delay your case. If the appeal process takes 12 weeks and results in a further decision that you are not totally disabled, it can be easy to lose hope.
If you have submitted all the evidence that is available from your treatment providers in support of your initial application for long term disability benefits, you may wish to consider retaining legal representation to start a lawsuit rather than going through the waiting period of waiting for final decision.
If you choose to submit a disability appeal, you can do so on your own or with the help of a lawyer. You will need to submit an appeal letter setting out the reasons that you believe that the insurer made the wrong decision. You will want to submit medical records which provide the insurer with any information that was not included in your initial application for benefits. Insurance companies will deny claims where it appears that the medical condition is not described in detail and where the medical report and application do not provide any evidence about functional limitations caused by the disability. If there were outstanding test results or further specialist appointments since the claim was initially denied, they should be submitted in support of the claim.
The insurer will review any information submitted in support of the appeal, all of the information submitted for the initial application for benefits and will then provide a decision. The insurer may require further information from your doctor or any specialists you have seen. They may also conduct a further telephone interview with you or your doctor.
If you were receiving ongoing benefits and the insurer terminated your benefits because you failed to participate in a proposed rehabilitation program, it is unlikely that your appeal will be successful unless you have new medical evidence that this program is not appropriate. Furthermore, if you were receiving benefits and the insurer chose to conduct surveillance, it is unlikely that an appeal will be successful. In either case, you should see legal advice and the best course of action is likely to challenge the insurer’s denial in court.
If your claim was denied because the insurer says that your disability was caused by a pre-existing condition, you should seek advice from an experienced long term disability lawyer before submitting an appeal. It is important to know the policy language and to understand the medical evidence before taking any position on the appeal. A poorly drafted appeal dealing with a pre-existing condition denial could simply provide the insurer with a better case for denial.
Very few disability claim appeals will result in an decision to accept the claim and pay monthly benefits. That does not mean that you should lose hope. It means that you will need to sue the insurer to obtain the financial support you need while you seek treatment and work on recovering from your disability.
Most Canadians have never been involved in a lawsuit. Your long term disability lawyer will advise the insurer that you have legal representation and that any further communication will be with the lawyer. The lawyer will request a complete copy of the disability claim file and the denial letter. The lawyer will need to obtain a copy of your benefit booklet or a copy of the insurance policy in order to confirm your long term disability coverage.
Very few court actions involving long term disability claims will go to trial. Starting a lawsuit means that the insurer will appoint a lawyer to represent it and the insurer will file a Statement of Defence. The legal process usually results in a settlement which involves ongoing monthly payments because the insurer accepts that you are totally disabled or a settlement for a lump sum payment representing a compromise of the disability benefit claim.
The limitation period refers to the deadline to start a lawsuit. The limitation period runs from the date that you were entitled to start a lawsuit to enforce your right to disability benefits for a period of 2 years in Ontario. As soon as you know that your claim status – that it was denied by the insurance company or that your claim for monthly payments was terminated, you should assume that the limitation period has started to run. If a period of many months has passed since you received a decision on your claim, you should act quickly and speak with a long term disability lawyer. It is possible that you will need to start a lawsuit immediately and you will have no opportunity to appeal.
There is no reason to try to make these decisions without information from a lawyer experienced in handling long term disability claims. We provide a free consultation, in French or English, to ensure that your rights are protected. In most cases, we can offer to represent you on a contingency fee basis. This means that you do not pay legal fees unless you win or achieve a settlement on your case.
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