Long term disability insurance denied? Contact a Toronto Disability Lawyer

Navigating the Long Term Disability Minefield

The whole point of having long term disability insurance coverage is to have the peace of mind that it will be there if you need it. Unfortunately with some Group Disability Insurers the stress is just beginning. Is Your Long Term Disability Insurance Denied?

From the time you make your claim with the numerous forms , interminable delays , incessant repetitive requests for more medical information, the seeming inability to speak to anyone in authority, it is as if the Insurers have created a purposeful strategy to frustrate.

Most people initially receive a standard rejection letter which, believe it or not, asks for more medical information. There should be a realization that the claim is being “handled”, i.e. denied. The best option for you is not to panic and find out your rights.

You should check the Employees benefits booklet, which should state that as an employee you are entitled to receive a percentage of income for up to two (2) years if a claimant is unable to perform the essential duties of their “own occupation “, as determined by a qualified Physician. Legally, this is a good place to be.

What you should also know:

  •  The law says that if there is a conflict between the entitlements set out in the Employee booklet and the Actual Group Policy (which an employee never sees) the booklet prevails.
  •  The Insurance Company cannot discuss your medical details with your Employer so an Employee should never sign consent to do so unless this is their choice to do so.
  • Once your Physician determines that you cannot perform the essential duties of your own occupation, it is the Insurance Company that has the legal burden to prove that a medical condition does not meet the standard.

 

Common Issues With Long Term Disability Claims

The following will provide you with a brief oversight on some of the common issues that you may encounter in the course of your Long-Term Disability claim.

 

1. Rejection based on a “Pre-existing Conditions”: A “pre-existing condition” is a common term in many policies of Insurance companies to describe any medical conditions which may have existed prior to the coverage under the employer’s group benefit plan. The pre-existing exclusion period, which is the period that will disqualify entitlement for submitting a claim for a condition that arose prior to having such coverage may be anywhere from the commencement of the new employment up to two (2) years. Most claims for disability which arises shortly after the coverage begins will likely be investigated to see if benefits can be denied on the basis that it was a pre-existing condition. If there has been a denial of benefits because of a pre-existing condition, it may be a complex task to determine whether or not the insured has a case.

2. Coverage Period: During the employment relationship, a person may submit an application after he or she has been enrolled in the Group Benefit’s Plan, this is usually after a period of three months. However, it is important to review the benefits booklet to verify the coverage period. Once this is done, a claim should be submitted soon after he or she has become disabled.After the employment relationship has been severed, a person may submit an application for disability benefits anytime during the notice period. However, the statutory notice period will be the best time to submit an application for benefits to ensure that there will not be an issue with respect to eligibility.

3. The Onus to Prove Deniability: Generally, in order for the insured to be entitled to benefits they must provide the insurer information demonstrating that he or she is “totally disabled” within the meaning of the disability insurance policy. In addition, the insured may be cut off their entitled benefits as a result of a change of definition of disability, ultimately denying benefits based on the insured’s improvement of health. If this occurs it will be the insurer’s responsibility to show that the insured is no longer disabled, usually with contrary medical opinion.

4. Maintaining Coverage: Where an employer refuses to assist in processing disability claims or ends disability coverage at the end of the statutory notice period, the employer may find itself held responsible for the employee’s disability if the employee becomes disabled during the reasonable notice period. The employer may find itself responsible for paying the disability payments until the employee recovers or potentially to the age of 65.

 

Be realistic; do not wait until the delay and the loss of income forces you to consider returning to work before your medical situation allows it.

If you are experiencing any of these difficulties with respect to receiving Employer sponsored Long-Term Disability or if you simply have any questions, you should contact an experienced employment and disability lawyer to guide you along the way.

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