An illness or injury that results in a short- or long-term disability can drastically change a person’s life. Every day activities, as well as work and home life, are often largely disrupted and limited. It is for situations like these that many people have coverage, either through a public or private insurance company.
Unfortunately, even when a person has insurance coverage, this does not mean that his or her disability claim will be approved. In fact, more than half of all disability claims with the Canada Pension Plan (CPP) are denied, meaning your claim is more likely to be denied than approved. These denial numbers are likely higher for private insurance companies such as Manulife and Sun Life.
If that has happened to you, you may be anxious and unsure of your next steps. If you are unable to work due to your illness or injury, the added stress of a denied short- or long-term disability claim can be overwhelming.
The legal team at Grover Law Firm has helped many Canadians successfully fight denied disability claims. In this article, we will take a closer look at long-term and short-term disability claim denials and how you can fight back and win. To start, it’s important to understand what a disability claim is and what it involves.
Disability Claims and Coverage
Disability insurance is divided into two categories: short-term disability and long-term disability. Generally, short-term disability benefits provide coverage for injuries or illnesses up to 6 months. Long-term disability benefits begin when short-term disability ends and can last up to 2 years or longer, depending on the type of plan.
Many employers offer disability insurance to their employees. This may be with a private insurance company such as Sun Life, Manulife, or Blue Cross. In addition, disability coverage is available through the Canada Pension Plan (CPP), depending on eligibility.
Claims through a private insurance company
Each insurance company has its own process for submitting and responding to a claim. The details also depend on what type of plan it is (whether personal or through an employer).
Some important steps to submitting a short- or long-term disability claim include:
- Providing a personal statement: This should include important details about your illness or injury, such as how it occurred, what the symptoms are, and when they started. In addition, it should outline what work duties are impacted due to your symptoms and what treatments you are currently seeking.
- Cooperating with your insurer: Your insurance provider will request information about any benefits you are eligible to receive from other sources, such as workers’ compensation, Canada Pension Plan, employment insurance, or others.
- Providing a statement from your physician: This report will include detailed information about your injury or illness and treatment plan. It should include supporting evidence, such as test results, consultation reports, and other medical documentation regarding your diagnosis and treatment. Your doctor will also detail your limitations due to your symptoms.
Once a claim is submitted, you will be assigned a case manager to handle your application and provide information and updates on the process.
Claims through the Canada Pension Plan (CPP)
Disability benefits may also be available through the Canada Pension Plan. To be eligible, an illness or injury must be either terminal or a “severe and prolonged” disability. “Severe and prolonged” means the CPP determines it usually or always prevents you from doing any substantially gainful work and is likely to be long-term and of indefinite duration, or is likely to result in death.
In order to apply, two forms are required: the application form and the medical form. Forms can be mailed or dropped off at a Service Canada office.
Although the CPP aims to make a decision within 120 calendar days, there are provisions for priority processing for certain serious or terminal conditions, such as many types of cancer, ALS, Parkinson’s, and quadriplegia.
Denied Claims: The Denial Letter
If you have received a denial letter, it can be very discouraging and stressful: You need these benefits to make ends meet and care for your needs. However, as mentioned above, disability claims are more likely to be denied than approved. So if your claim was denied, you are not alone. Many people have successfully fought back and won a claim that was initially denied.
Insurance companies are required to provide the reason a claim was denied. Your denial letter will be key in determining why your claim was denied and will give you clues as to how you can fight back.
There are a number of reasons to deny a disability claim, including:
- The illness or injury is not serious enough to qualify
- The illness or injury is due to pre-existing conditions
- The treatment plan does not match the diagnosis
- The illness or injury is excluded from the policy
- The claim did not meet policy deadlines
Your denial letter may include details from your insurance policy or information from your medical reports as evidence to support the decision to deny your claim. Whatever reasons or evidence are listed on your denial letter gives you a starting point on how to successfully respond.
Another crucial detail listed on the denial letter is the date. This date is very important because this is when the clock starts ticking for deadlines in the appeals process.
Denied Claims: The Appeals Process
Once a disability claim is denied, there are two options: file an appeal with the insurance company (internal) or file a lawsuit with a disability lawyer (external).
Internal appeal with the insurance company
For most people, following the internal appeal process with the insurance company seems like the most appealing option. For one thing, there is no need to find and consult a law firm, and there are no additional costs or legal fees.
Sometimes there are advantages to filing an internal appeal with the insurance company. For example, the claim may have been denied due to a simple error or oversight in the application.
Once the error has been corrected or additional information has been provided, it may be approved. In these cases, it can be easier and faster to appeal directly to the insurance company.
Personal injury lawsuit
Another option is working with an experienced disability lawyer to file an external appeal or a personal injury lawsuit against the insurance company.
There are a number of advantages to this option:
- Personal injury lawsuits are reviewed by a neutral party. When you follow the internal appeals process, the person reviewing your claim works for the insurance company. Intentionally or not, he or she is biased in favour of the insurance company. Although adjusters are bound by law to follow the terms of the contract and provide compensation when necessary, it is to their benefit to deny claims. However, in the external appeal process, a neutral third party reviews the claim. This may be a judge, arbitrator, or another person. He or she is not biased and has no incentive to deny legitimate disability claims.
- A lawsuit ensures you receive equal representation. During the internal appeals process, the insurance company has an entire team on its side to fight for its interests. When a person goes through the appeals process alone, he is often outmatched and outnumbered. Working with a disability lawyer levels the playing field and removes the advantage from the side of the insurance company.
- Working with a disability lawyer offers peace of mind. There are a lot of details and deadlines to follow in the appeal process. Gathering evidence and consulting experts to build a strong case takes time and can be stressful, especially if you are not experienced with the process. A disability lawyer knows how insurance companies operate. Attorneys understand the deadlines and details of insurance policies and often have contacts with experts who can help prove your case. When you work with a law firm, you can have peace of mind, knowing that your case is in good hands.
As with the internal appeals process, a lawsuit also has filing deadlines. Generally speaking, the deadline to file a personal injury lawsuit is 2 years, but it may be shorter depending on the specific details. So if you decide to pursue an internal appeal process first, the longer you spend in the internal process, the less time will remain to file a lawsuit afterwards if you decide to do so.
Steps to a Successful Appeal
Whether you decide to go it on your own with an internal appeal or use the help of a law firm, it is possible to fight the insurance company and win. To do so, you will need to understand your contract and identify weak areas to build a strong case.
Understand the terms of your contract
Your insurance policy is a legal contract between you and your insurer. It provides the basis for your eligibility for compensation. Unfortunately, though, these policies are not all the same, and there are key details that can have a substantial impact on your claim.
Make sure you understand what your policy states in a few key areas:
- Definition of disability: Not all policies define disabilities in the same way. For example, some contracts define “totally disabled” as being unable to perform any type of work. Others define it as being unable to perform the duties of your own occupation. Make sure you understand the terms and definitions set out in your policy.
- Amount of coverage: How much coverage does your policy include, and for how long? Some long-term disability benefits provide coverage until age 65, but others only provide coverage for 2 years. In addition, some policies may replace 60 to 80 percent of your income up to a certain monthly limit.
- Timelines and deadlines: Your policy will also include timelines and deadlines for claims and coverage. Some policies change definitions or limits after a certain amount of time. There are also deadlines on when a claim or appeal must be filed in order to be eligible for coverage.
The “legalese” in insurance policies can be difficult to understand. If you need assistance understanding your contract, a consultation with a disability lawyer can help you know where to start.
Build a strong case
As mentioned above, your denial letter will outline the reason the insurance company denied your claim. This will help you identify weak points in your claim and give you a starting point on where to strengthen your case.
You can request a copy of your file from your insurance company to identify any gaps in your original claim and where you can offer additional information or evidence.
For example, was the reason for denial the seriousness of your illness or injury? Maybe the issue is not that your illness or injury isn’t serious enough, but rather that there was insufficient medical evidence to support it. With that in mind, it can help to ensure you provide detailed medical records to prove the extent of your symptoms.
You may also need to request additional medical tests or treatments to address the insurance company’s concerns or doubts.
Independent experts can also help build a strong case. They can provide written testimony to prove the medical and vocational limitations due to your illness or injury. In addition to experts, family, friends, and coworkers can offer testimony about the effects of your disability on your life.
The Disability Lawyers at Grover Law Firm Are Here to Help
Dealing with a denied long-term disability claim is not easy, but it is possible to fight back and win! Whether you decide to go it alone or work with an experienced disability lawyer, a free consultation with our firm can help you decide your next steps.
We want to see you receive the long-term disability benefits you need and deserve. Call the number above or fill out our online form to learn more about what we can do for you.