“Totally Disabled.”   “Own Occupation.”
“Any Occupation.”   “Internal appeal.”

What does it all mean and what should you do when you’re faced with a claim denial or when your LTD benefits get cut off?

Longterm disability (LTD) protection is supposed to be there for you when you need it. If you have to stop working because of physical or psychological difficulties, this insurance should help to carry you through.

But even though you aren’t able to work, your insurance company might try to tell you that you don’t qualify as “disabled” and aren’t entitled to benefits. They might deny your claim in the first place, or they might suddenly cut you off, even after paying for years.

What’s going on here? And what can you do about it?

What it means to be “disabled”

All LTD policies are different, and you will need to speak with a local LTD lawyer to get advice about your policy in particular. But in most cases, the insurance policy only protects people if they meet a very technical definition of the (archaic and politically incorrect) word, “disability.”

In many cases, for the first 2 years of benefits, you will be deemed to have a qualifying “disability” that entitles you to benefits if you are unable to perform the key tasks required by your regular job. This is sometimes called the “own occupation” test.

So, for example, if you worked in a very physically demanding position that required you to lift heavy items all day, you would probably be deemed “totally disabled” and entitled to coverage as long as you remained unable to manage that sort of regular heavy lifting.

But for many policies, the test you have to meet to qualify as “disabled” changes after that initial period, and things get much more difficult.

To continue to qualify after the “test change” date in the policy, you will likely need to show not only are you unable to do your old job, but also that you can’t do any job that’s reasonably suitable for you. This is sometimes called the “any occupation” test, and it can be a difficult threshold to meet.

In the case of our heavy-lifting employee example, maybe she can’t keep up her previous very physical job with her injuries, but maybe she could handle something less labour-intensive that she happens to be qualified for, like working at a computer. In that case, even though she still can’t do her old job, the fact that there’s another suitable job she could do means that she might stop meeting the definition of “disabled” in the policy. As a result, her benefits might get denied.

You don’t have to accept your insurance company’s decision!

It’s unfortunately very common for disability insurance companies to deny your claim and cut off your benefits because they think you can go back to work, even when you and your doctors know you won’t be able to manage it.

But you don’t have to just accept this. When LTD insurers make mistakes (or “mistakes”), they need to be set straight.

To fight an insurance company’s wrongful termination of your benefits, you will usually need to get medical evidence (or more medical evidence) that explains exactly what you can and can’t handle due to your condition, and why.

Often, your family doctor can help provide this medical evidence, but it’s helpful to get opinions from other medical and quasi-medical sources as well, including from any specialists you are referred to and from the treatment providers who see you regularly.

If you have a good relationship with your employer, they may be able to help with your claim as well, since they can consider your medical limitations and whether it’s practically possible to accommodate those limitations in their workplace. (Of course, if your employer is failing to reasonably accommodate you, that can raise a whole other issue, and that’s when it’s a good idea to talk to a local employment and discrimination lawyer.)

It’s also possible to hire your own medical and other specialists to conduct a detailed assessment of your condition and provide an expert opinion as to what you can handle and what you can’t.

It may be necessary to take a careful look at what other jobs out there you might be able to handle, and whether you they are actually “reasonably suitable” for you given your education, training, experience, and the remuneration you are used to receiving. A skilled tradesperson who can’t continue his or her regular work might be able to physically handle a part-time, minimum-wage job taking tickets at a movie theatre instead, but that that’s probably not a reasonably suitable alternative job they should have to settle for – even if the insurance company thinks so!

Fighting back: responding to an improper denial

Sometimes insurance companies will have internal “appeal” procedures to allow you to dispute their denial without starting a lawsuit or even hiring a lawyer. This usually involves writing a letter and providing additional evidence that might prompt them to reconsider their decision.

Unfortunately, these internal appeal procedures rarely go anywhere, and once an insurer has made up its mind, it often takes the threat of a lawsuit before they will change it.

There’s where a local LTD denial lawyer comes in. Often just the serious threat of a lawsuit from a firm that specializes in LTD disputes like Nolan, Ciarlo LLP can prompt an insurance company to reconsider an unfair decision.

An experienced LTD lawyer will be able to review your case and give you an opinion about whether or not you are likely to be able to succeed. A disability insurance lawyer will help you collect and present the medical and other evidence you need to prove that you qualify as “disabled” under your particular policy. And a local LTD denial law firm will be able to negotiate with the insurance company to reach a fair resolution of your case, or, if the insurance company refuses to be reasonable, your lawyer can take your case to court and force the insurance company to honour its obligations.

This is why it’s always a good idea to consult with local LTD denial lawyers like Nolan, Ciarlo LLP when you end up in a dispute with your insurance company.

Our LTD consultation is free, so why not find out how we can help?


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April COVID-19 Update

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