Long-Term Disability is peace of mind insurance that is there to ensure that, in the worst of circumstances when someone is rendered unable to work, that there is money coming in to make sure the bills get paid and food can get on the table.

Proving a disability claim, no matter how legitimate, can be difficult.  Insurance companies may deny your claim for a number of reasons, sometimes for no other reason than to support their bottom line.  Insurance companies may use medical evidence and policy restrictions to avoid payouts. They may go so far as to monitor your social media accounts or hiring private eyes for evidence of misrepresentation. Disputing an insurance denial can be difficult because of the restrictions listed in the policy and the complicated legal issues that can arise out of your insurance contract.

Common Reasons for Long-Term Disability Denials

A common reason long-term disability benefits are denied is a lack of sufficient medical evidence to support the disability. When someone applies for disability benefits, they must prove to the insurer through medical documentation that their claim for being disabled from employment is supported by their clinical records.  Ideally these records should clearly demonstrate the severity of the disability, the impact the disability has on their ability to complete the duties of their employment, and the expected duration of the disability, if available. If the clinical records provided to the insurance company are incomplete, inconsistent, or do not adequately support a disability, the claim may be denied.

Another common reason for denial is a disagreement between the applicant’s doctor and the insurance company’s medical professionals. Insurance companies often employ their own medical experts to review disability claims. If these experts disagree with a treating doctor regarding the severity of the disability or the impact it has on the individual’s ability to complete the duties of their employment, a claim for long-term disability benefits may be denied.  Often treating doctors expect deference as to their decision from insurance companies and do not realize that if their records or reports do not specifically address the requirements of meeting the definition of “disabled” under the policy of insurance, a claim will be denied.

The reason for denial of long-term disability benefits most often seen due to an alleged misrepresentation of a material fact in the application for long-term disability insurance.  The insurance companies will base their decision to insure an individual based on the information provided to them in the insurance application.  If material facts (for example a pre-existing medical issue, or that an individual smokes cigarettes or engages in risky recreational behaviour like skydiving) is not provided to an insurance company during the application process, the insurer may use that misrepresentation as a basis for denying a claim under the policy of insurance.  The insurance company will adopt the position that the insured misrepresented material facts to them and, had they been aware of the material facts, they never would have issued the policy of insurance in the first place.

Change in Definition of “Disabled”

Even if your long-term disability benefits are approved, that does not mean the insurance company can’t cut you off.  There can be many reasons an insurance company would cut off ongoing long-term disability benefits, however the most common is when there is a change of definition as to what being “disabled” under your insurance policy is.

Most long-term disability policies provide that for you to be considered disabled under the terms of your insurance for the first two years, you need to be unable to complete the duties of your employment due to your disability.  However, after two years the definition of disabled often changes from being unable to complete the duties of your employment to being unable to complete the duties of any employment.  This is often called the change from “own occupation” disability to “any occupation” disability.  It is important for individuals and their treating doctors to understand this distinction to avoid having legitimate long-term disability benefits cut off.

Strict Timelines Apply

Timelines matter for disability claims.  There are often time limitations in place in your insurance contract that will prevent you from taking legal action after receiving a policy denial.  It is important to move quickly when looking for legal advice.

Insurance companies will often have internal appeals processes to allow you to challenge a denial or cut off your long-term disability benefits.  Often going down an appeal route is a waste of time as you are usually appealing the decision to the same insurance company that already denied your claim while having access to your medical records.  If your appeals process drags out too long you may miss the limitation period to start a lawsuit to enforce your rights.

Yukon Long-Term Disability Lawyers

If your legitimate long-term disability claim has been denied, contact our experienced long-term disability lawyers today for a free consultation.