Navigating Denied Long-Term Disability Claims in Ontario: A Lawyer’s Perspective
Applying for long-term disability (LTD) benefits in Ontario is something that nobody ever wants to experience. But if you are unable to work due to a debilitating medical condition—whether physical, psychological, or a combination of both, LTD benefits can be a critical lifeline. These benefits are often times offered through a group insurance policy by an employer. LTD is designed to provide critical financial support in times of need, giving you the stability to focus on recovery without the immediate pressure of lost income, or the worry about being fired from your job while going through the healing process.
However, making sure you qualify for LTD benefits is often filled with challenges, along with ensuring you get enough coverage to properly heal. Up front denials by insurers are increasingly more common, as are denials for buyouts, and many people are left feeling overwhelmed and uncertain about what to do next.
Understanding your legal rights and options after an LTD denied claim is crucial to navigating this process effectively. In this blog, we’ll explore why claims are denied, what steps you can take to appeal or challenge a denial, and how legal representation can help you secure the benefits you deserve. If your LTD claim has been denied, just know that you are not alone—and knowing your options is the first step toward a just resolution.
Why Are LTD Claims Denied?
Insurance companies are businesses, and their profitability depends on controlling payouts. As a result, LTD claims are often subject to rigorous scrutiny, and convoluted denials are not uncommon. The most frequent reasons for rejection include:
- Insufficient Medical Evidence
Insurers often argue that the medical documentation provided does not adequately support the claimed injury or disability. They may require detailed reports from multiple healthcare providers or challenge the legitimacy of the diagnosis itself, forcing you to spend energy and time where you should be focused on healing.
- Failure to Meet Policy Definitions
Many LTD policies distinguish between being unable to perform one’s own occupation versus any occupation. Insurers may deny claims if they believe the claimant can perform some form of work, even if it is less demanding or unrelated to their previous role, or even if it pays less.
- Administrative Errors
Claims can be denied for procedural reasons, such as failing to meet submission deadlines or providing incomplete information. This forces the claimant to double and triple check their applications to make sure valuable time isn’t lost on appeals.
- Disputes Over Pre-Existing Conditions
If the insurer suspects the disability arises from a condition that existed before the policy coverage began, they may reject the claim under pre-existing condition clauses.
- Surveillance or Misinterpretation
Insurers sometimes conduct surveillance or misinterpret activities as inconsistent with the claimed disability, even when such activities are limited and within medical recommendations.
Your Legal Rights as a Claimant in Ontario
If your LTD claim is denied, it is essential to understand that you are not without options. Ontario’s legal framework provides several avenues for challenging these decisions. These options include:
Internal Appeals
Most insurance policies include an internal appeal process. This allows claimants to submit additional evidence or clarification in response to the denial. While this step can be an effective starting point, it is important to approach it strategically, since you are dealing with the denying party. You may want to first make sure you strengthen your medical evidence, so working closely with your healthcare providers. This can include detailed medical assessments that clearly demonstrate your condition and limitations and the timing of your disability. You may also want to seek expert legal advice early on. It doesn’t mean a lawsuit, but getting those familiar with the law to review your case and help you craft a compelling appeal.
Litigation
If an internal appeal does not resolve the issue, you have the right to take legal action. Under Ontario law, insurance companies owe a duty of good faith to their policyholders. Denying a valid claim without adequate justification may constitute bad faith. Filing a lawsuit can result in compel the insurer to pay benefits owed and, in some cases, additional damages for the undue hardship caused by the denial.
Human Rights Complaints
Mental health conditions and other invisible disabilities are often misunderstood or unfairly scrutinized. If you believe your denial stems from discriminatory practices, you may have grounds to file a complaint under the Ontario Human Rights Code, which protects individuals from discrimination based on disability. [I would remove this section, as this avenue isn’t really seen in LTD litigation. Instead, this type of situation could be remedied by a punitive damages claim.]
Acting Quickly: Limitation Periods
In Ontario, legal claims are subject to strict time limits under the Limitations Act, 2002. Generally, you have two years from the date your claim was denied to commence legal proceedings. Failing to act within this window can prevent you from pursuing your case, so it is essential to seek legal advice as soon as possible.
How a Lawyer Can Help
Challenging a denied LTD claim can be overwhelming, especially while dealing with the physical or mental challenges of a disabling condition. This is where experienced legal counsel can make a significant difference. Firms like Vice & Hunter LLP specialize in assisting clients with LTD claims. We can:
- Interpret Policy Terms: Understanding the fine print in your policy is crucial to identifying grounds for appeal or litigation.
- Gather Compelling Evidence: We can help you compile the medical and occupational evidence needed to substantiate your claim.
- Negotiate with Insurers: Skilled negotiation often leads to settlements, avoiding lengthy court battles.
- Advocate in Court: If necessary, we can represent you in litigation to ensure your rights are upheld.
Practical Tips for Strengthening Your Claim
Know Your Policy – Read your LTD policy carefully to understand the definitions, exclusions, and deadlines that apply.
Document Everything – Keep detailed records of medical appointments, correspondence with the insurer, and any relevant expenses or hardships caused by the denial.
Engage Legal Support Early – Consulting a lawyer from the outset can help you avoid common mistakes and build a stronger case.
Be Mindful of Surveillance – Insurers may monitor your activities. Always follow your doctor’s recommendations, and be consistent in how you represent your condition.
Taking Legal Action if You’re Denied
A denied LTD claim is not the end of the road. With the right knowledge, preparation, and legal support, you can challenge the denial and secure the benefits you are entitled to under Ontario law.
If your LTD claim has been denied, don’t hesitate to reach out to us for an initial consultation. We’re here to provide you with the guidance and advocacy you need to secure the benefits you’re entitled to.
This information is for general purposes only and should not be considered legal advice. For personalized assistance, consult a qualified lawyer.
