Why Were My Long Term Disability Benefits Denied?

Published on December 6, 2017

Long term disabilities can significantly impact your life; not only physically, emotionally and socially, but also financially.  If you have a long term disability or illness, it can be devastating to learn that your long term disability claim has been denied or that your benefits will be cut off.   

In Ottawa and across Ontario, long term disability insurance companies are corporations with one ultimate goal:  to make a profit.  They do not make profits by paying long term disability benefits to everyone who submits a claim.  Many insurers will use any available excuse to refuse your claim or terminate your benefits.

Here are just a few of the reasons the insurer may rely upon to refuse your claim for long term (or short term) disability benefits:

Failure to Meet the Definition of Disability

The most common reason why a long term disability claim is denied is because the individual has failed to meet the definition of “disability.”  Generally, under most insurance policies, the disability test for the first two years is whether you are impaired from the duties of your old job.  After two years, the test changes to whether you are impaired from doing any job for which you are reasonably qualified based on your training, education and experience.

Failure To Submit Paperwork on Time

If the required application documents are not sent in to the insurance company in a timely manner (that is, per the policy’s qualifying period), long term disability claims may be denied. That’s why it’s important to take action right away.

Pre-Existing Medical Condition & Policy Exclusions

If you have a pre-existing medical condition, many private insurance companies will exclude benefits.  A policy might also exclude injuries that occurred as a direct result of various events (for example, alcoholism) and, as such, benefits could also be denied for this reason.

Reliance on In-House “Experts”

Many insurance companies have teams of “medical partners” or “consultants” who are paid to review your claim and provide an opinion to the insurance adjuster.  These medical partners are are not neutral.  As mentioned, they are paid by the insurance company for their opinion and not surprisingly the opinions often differ drastically from what a person would expect from an unbiased doctor.  Many of these doctors do not even practice medicine in the sense of treating patients.  They make money by providing opinions and preparing reports for insurance companies.

Insufficient Evidence or Contradictory Evidence

If you failed to provide enough evidence (including medical evidence) to support how your long term disability has impacted your ability to work, your claim can also be denied.

Keep in mind, too, that insurance companies may rely on surveillance. That’s why it’s important to be careful what you post on social media. Anything that has the potential to sow seeds of doubt about your ability to work can impact your case.  The insurance adjuster may review your social media profile(s) while your claim is being made, or while your claim is ongoing.  The insurance adjuster may rely upon anything you have posted to bolster his or her impression of the extent of your impairment, sometimes unfairly, based on photos you have posted.

Failure To Meet Eligibility Requirements

In some cases, long term disability claims can be denied because you have failed to meet certain eligibility requirements. As an example, you may be covered under an employee group disability policy, but because you were not an employee for a long enough period or you worked less than the period outlined in the policy, your claim may be denied.

What Can Be Done?

The good news is that even if your disability claim has been denied, it may be possible to reverse the insurer’s decision or negotiate a settlement of your benefits.  If your long term disability claim has been denied, it is critical to get in touch with a personal injury lawyer who can fight for the compensation you deserve. Don’t waste any time filling out internal appeals on your own.

If you have been injured or disabled and are seeking compensation for a long term disability, contact Sean Giovannetti.  Sean is a personal injury lawyer with extensive experience, including prior experience practicing at two of Ottawa’s most prominent law firms where he represented insurance companies. For more information, please contact us today.