When you have been denied long-term disability in Toronto, you may feel angry, confused, or hopeless. The first thing to know is that this is a common occurrence. A lot of disability claims, unfortunately, are denied at first glance. So don’t be discouraged by an initial denial.
The next step to take is to contact a disability lawyer in Toronto and work on an appeal. Though not all long-term disability appeals are successful, a disability lawyer can outline what’s possible within your current circumstances.
Having contacted a lawyer and with supporting evidence of your disability claim puts the responsibility on your insurance company or the disability benefits system to disprove your argument.
What Is A Long-Term Disability Appeal?
Disability lawyers file long-term disability appeals usually in response to an LTD application being denied or when an insurer decides to cut off benefits.
You will notice in the documentation received in a disability denial that you have the option to appeal the decision. It is important to know what a long-term disability appeal is and its limitations in terms of what it can and cannot accomplish.
An LTD appeal is not a formal, objective, or even legal ruling on one’s right to long-term disability benefits. It does not take an insurer to court. It is not put forth before a neutral third party, a la a judge or arbitrator. An appeal is sent back to the same party who denied you in the first place and although it will make the argument that you do indeed qualify for long-term disability, it is ultimately still the decision of the insurer.
What Are The Advantages And Disadvantages Of A LTD Appeal?
The advantage of a long-term disability appeal is that you make a stronger case for yourself. Although you can appeal without a disability lawyer, it lends more credibility when you do. Disadvantages are plentiful, and you want to have a disability lawyer in Toronto at your side who understands how to navigate around these issues.
- The decision is still made by the same party who denied you. This is a disadvantage as there was a reason they assigned to your case as to why you were denied in the first place. In most cases, there is an incentive on their part to uphold that denial. Appeals don’t always work, especially with private insurance companies, and this is the reason why.
- There is no neutral third party. Everything is still done internally. If your appeal is rejected, there isn’t much that can be done after the fact. An insurer can do that at will and with no repercussions. Although you may be able to appeal a second time, this will likely result in a similar result.
- An appeal takes time. In some cases, months and even years. After you connect with a lawyer, there isn’t necessarily a motivation on the part of the party you’re making the appeal to complete the process quickly. An appeal can drag out, resulting in frustrations and struggles, and some claimants lose their right to pursue a legal claim against some insurers. This is a strategy sometimes used to ensure they aren’t forced to pay the disability benefits that they owe.
Your Step-By-Step Guide To Making A Long-Term Disability Denial Appeal
If you want to make a long-term disability appeal, here is everything you need to know about exactly how to do that. Refer to this step-by-step guide to ensure you aren’t cut off abruptly or are left wondering what to do next.
- What is your long-term disability appeal deadline? If you miss the deadline to file an appeal, that’s it. You can’t do a whole lot to move forward from there. When you receive the denial letter from your insurer, the deadline to file an appeal is typically included in the last few paragraphs. If you have not received any notification in writing outlining a denial, contact your insurance company and ask them for denial in writing. An appeal deadline may be given in one of two ways: as a specific date, i.e. July 17, 2022, or as a number of days, such as “30 days from the date of this letter.” Do not wait to contact a disability lawyer or file your appeal, as these are often hard deadlines. You don’t want to give your insurer any additional reasons to deny processing your claim.
- Notify your employer that you will not be returning to work, that you disagree with the insurance company’s assessment, and are appealing the decision. When a claim is denied, the insurer will send a letter to your employer notifying them that you cannot work and do not qualify for long-term disability. The result is your employer’s going to contact you to get you back to work. Advise them that you aren’t able to. A lot of employers will be understanding. Some won’t, however. An employer might even demand that you return to work and might threaten your job security. When an employer gets aggressive like this, have your doctor write a new note directly to the employer clarifying that, as your physician, they are putting you off work regardless of what an insurer’s opinion may be. Doing this will put you into the category of having the right to ongoing accommodations, underemployment and human rights laws, including permission to allow you to continue on unpaid sick leave.
- Gather your documents to appeal. You will need several things in order, including the denial letter from your claim representative:
- A copy of your group insurance booklet describing long-term disability benefits and what those are.
- Your union’s collective agreement, if applicable.
- A copy of your medical file from your family doctor with everything from as far back as when symptoms started to present.
Your medical file is particularly important here as it serves as proof of your claim. Maintain a clean copy of your medical file to send to the insurance company. Suppose there is any medical testing not included. In that case, you might want to connect with the relevant parties – whether it’s a hospital, specialist, or whomever – and obtain this information to include with your file.
- Identify what other benefits you are eligible to apply for, as it can take time for an appeal to be processed. If months go by and your appeal still hasn’t been examined, that’s an extended period of time where you have no income coming in and might be relying heavily on savings. Identify any possible sources of income or financial support that are accessible to you. Employment insurance (EI) sickness benefits, available creditor disability benefits, bank loans, and/or credit cards are all places you may be able to go to help carry you through this difficult time. This part of the appeal process is all about coming up with a way for you to live comfortably as a Plan B of sorts while your appeal is in waiting.
- Analyze your disability letter before filing an appeal. Note the reasons your insurance company gave for denying your claim. This will form your strategy on how to proceed. Insurance companies are required by law to give a reason and will usually openly put these in writing. The best thing you could hope for in analyzing your letter is that the reasons are specific. An insurer may even list documents or information they require to reconsider. If you do see this, it can help make the appeal process easier and may even be a sign; there’s hope that you will be approved once the indicated documentation is submitted. Should they outline that they disagree with the certain information or that a medical opinion is unclear, focus on resolving that disagreement with new information and/or new medical documents supporting your argument. Some of the common information an insurer requests in an appeal are the following: support and clarification on your medical diagnosis, what functional limitations you have, a detailed explanation on how these limitations and/or other symptoms interfere with you doing your work, a clear outline of physical demands and job requirements, copies of medical records or reports from treatment providers, medical evidence, information from family or co-workers supporting your argument, and work history.
- Write your appeal letter. A disability lawyer in Toronto can help tremendously with writing an effective appeal letter. You want to ensure this letter responds to every point in the denial letter and accompanies the relevant documentation. An insurer may have some specific questions that you will want to address in your appeal response. If your denial letter does not indicate a reason for your denial and/or is vague about it, look for other information and clues on where to focus an appeal. If you’ve completed a Transferable Skills Assessment or something similar and you’ve been denied on the count that other employment is available to you, look for ways to delegitimize this assessment, arguing it makes faulty assumptions. Have your doctor review assessments like these and offer advice, assuming your family physician is right with you and on your side. Ask an insurance representative for more information if an insurer refuses to give a reason or simply states that you do not qualify. Do some digging in the letter to look for clues on structuring an appeal letter. In some ‘no reason denials’, it may make more sense to skip the appeal process, head straight to court, and make a legal claim against them. Consult your disability lawyer for further information on how to proceed.
- Lastly, prepare your appeal letter and package. Once everything’s written and assembled, all that is left is to send it. Be sure your appeal does not utilize a lot of legal analysis and instead simply provides information and focuses on addressing the missing components indicated in the denial letter. Once an appeal letter is received, expect a response within 30-60 days from the insurer.
When To Appeal And When Not To Appeal Disability Benefits
You don’t have to appeal a long-term disability benefits denial, and it’s not recommended to do so in some cases. Instead, consult with a disability lawyer before deciding to appeal. They can provide input on whether it’s worth pursuing. An experienced disability lawyer sees these sorts of denials regularly. They’ve won and lost cases. They know what’s likely going to succeed and what won’t.
To answer the question of should you appeal a long-term disability benefits denial, you can proceed without a disability lawyer, as mentioned. However, if they state it’s highly unlikely to change the outcome, it can be better to avoid wasting time and money in pursuing a case that goes nowhere. Also, in most cases, you can appeal and re-appeal, and re-appeal again should you so choose, but it might only end in frustration and more time lost on something that makes you unhappy.
It must also be stated you have a two-year limitation on starting a legal claim to force an insurer to pay you what is owed. If you miss this period – under any circumstances – you forfeit the opportunity to recover long-term disability benefits even if they are owed to you by law.
What Is An Alternative To A Long-Term Disability Appeal?
It may be more advantageous in some cases to make a legal claim as opposed to pursuing appeals if you are denied long-term disability.
A legal claim is when you work with a disability lawyer in Toronto to try and force an insurer to pay through the court system. This sends a more powerful message than an appeal. An insurer’s essentially forced to arrange a defence lawyer, increasing costs on their end and possibly motivating them to settle before it goes to trial. Furthermore, from an insurer’s perspective, they recognize that going to court could result in them being forced to pay what is owed to you in addition to a portion of your legal fees. Needless to say, the vast majority of long-term disability claims get settled long before they go to court, and it is another way to force an insurer’s hand.If you are experiencing an issue with a long-term disability denial in Toronto, a disability lawyer from Ava Gio can help. We have worked on many denials, appeals, and legal claims, and can make an accurate assessment of your unique circumstances, advising you on what the best use of your time and resources are moving forward.
