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When you are living with a disabling mental health condition, the last thing you need is your long-term disability (LTD) insurer threatening to cut off your disability benefits because you cannot afford the treatment they say you “must” attend. Yet this is a common and frustrating issue people face when dealing with long term disability benefit claims involving depression, anxiety, PTSD, and other mental health disorders.
If you are totally disabled, your insurance company cannot terminate your LTD benefits simply because you cannot afford treatment. However, it is important to understand treatment clauses in long term disability insurance plans and your rights, your obligations, and the steps you can take to protect your claim.
This blog explains what you need to know, why insurance companies make these demands, and how to respond in a way that protects both your health and your disability benefits.
Long term disability insurance is offered a part of a group coverage package to eligible employees as part of their employment contract. LTD coverage is designed to replace a portion of your pre-disability income if you are totally disabled throughout waiting period (or elimination period) and unable to work due to a medical condition. The primary purpose of LTD is to provide ongoing financial support during a significant period of illness or injury, allowing you to focus on recovery without the added stress of lost income. Depending on the specific definition of disability in the insurance policy, payment is usually tied to your ability to perform the essential duties of your own occupation and the impact of your symptoms on your ability to perform your activities of daily living.
To receive benefits, you must meet the definition of total disability as set out in your LTD policy. This typically requires providing objective medical evidence, including an attending physician’s statement and supporting medical records, as part of your application. The insurance company will review your application and make a decision based on the policy’s criteria.
While psychological illnesses cause disability and insurers do pay these claims, proving disability has unique challenges as the experience of symptoms is very personal and subjective. Your healthcare provider, whether it is a family physician or a nurse practitioner, can identify and treat a mental condition causing disability and document its existence. They can prescribe medication and recommend therapy such as counselling and psychotherapy.
If you are unable to take medication or have no access to drug benefits, this can result in a denied claim. In addition, the fact that counselling and psychotherapy are not affordable and may not be readily available often results in declined claims.
Most long term disability plans include provisions requiring you to be under appropriate medical care and “following an appropriate treatment program.” For mental illness claims, insurers often interpret this to mean:
Eligibility for LTD benefits requires a medical condition that prevents you from performing the essential duties of your job and appropriate medical care.
If you are navigating a LTD claim based on a specific mental illness, you may find these articles helpful:
Insurers argue that without treatment, you cannot recover and are not committed to your treatment. They are also aware that therapy and counselling is expensive and underfunded and often difficult to access.
Short answer: Not if the reason you are not attending is legitimate, documented, and outside your control.
Long answer: Insurers may suspend or terminate benefits if they believe you are:
However, they cannot cut you off for failing to attend treatment that is:
Canadian courts have held that disability claimants must make reasonable efforts, not perfect efforts. As long as the insurer is satisfied that you have made reasonable efforts and your barriers to treatment are legitimate, your LTD benefits should not be terminated.
Insurers will state that affordability is not their concern. It is a legitimate barrier to obtaining treatment, and you are entitled to explain it clearly. If you satisfy the definition of disability and simply cannot afford treatment, the insurance provider should pay.
If you cannot afford therapy, you should take the following steps to make sure that take these steps to ensure that you receive your long term disability pay.
Explain the cost, your financial situation, and why therapy is not feasible. While you can tell your claims examiner on the phone, it is far more effective to document your difficulties in writing.
Your nurse practitioner or family physician can write a simple note such as:
“My patient would benefit from psychotherapy, but cost is a barrier and they cannot access publicly funded services at this time.”
This demonstrates good faith by showing you have explored every available option for care. For example, you might consider:
Ontario’s Health Care Options directory can help identify publicly funded or low-cost services.
As part of their rehabilitation services, insurers sometimes offer:
These offers are designed to cover certain treatment needs. The fact that your insurer offers this treatment may make you skeptical; however, you may gain access to valuable care through your LTD insurer’s rehabilitation services.
However, you are not required to accept treatment that is:
You have the option to accept or decline these insurer-funded treatment offers based on your medical needs and comfort.
However, refusing insurer-funded treatment without a clear medical reason and supporting documents can create result in a legitimate denial of your income replacement benefits. The safest approach is:
Some insurance policies have a requirement that your condition must be documented by a specialist physician. This is an outdated requirement which is unlikely to be enforced if the insurer requires you to be under the treatment of a psychiatrist. Waitlists for psychiatrists and other specialists are extremely common throughout Canada.
If you are on a waitlist:
If you cannot participate in treatment because you are on a waitlist, the insurance company cannot claim noncompliance with the LTD plan. It is a systemic barrier, and insurers cannot reasonably deny your monthly benefits on that basis.
Many psychological conditions, including PTSD, severe depression, and agoraphobia, can make attending therapy difficult.
If symptoms interfere with accessing treatment:
It is common knowledge that symptoms themselves can limit a person’s ability to engage in treatment.
Insurers sometimes use treatment demands to build a paper trail for denial.
Common red flags include:
Here is a practical, step-by-step approach:
You should seek legal advice if:
If you need help navigating the disability claims process or have received a disability claim denial, reach out for advice from an experienced long term disability lawyer.
You should never have to choose between paying for therapy and paying your rent. Insurance providers know that psychological treatment is expensive and difficult to access, yet they regularly deny LTD claims for failing to participate in treatment.
The law does not require perfection. It requires reasonable efforts, and reasonable efforts look different for every person.
If you are doing your best, documenting your barriers, and staying connected with your doctor, your insurer should not cut off your long term disability benefits. If you receive a terminated or denied claim, you have options, and you do not have to navigate them alone.
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