Whether you pay for private insurance, or have group insurance provided to you at your workplace, your long-term disability claims may be denied.
Now you may be asking yourself “why me?”. The unfortunate truth is that many long-term disability claims are denied by insurance agencies. Often the rejections occur because of the following reasons:
While any/all of the above may influence your insurance providers decision in denying your claim, you do have options. But before you explore them it is very important that you read, and preserve, your denial letter. This letter will indicate certain key factors in their decision-making process. These include the provisions of the policy, the definition of disability in the policy, the reason(s) they denied your long-term disability application, information from your medical reports which they used to back up their statements, and the date the letter was written. (the date is of the utmost importance as it starts the clock on all future deadlines for both internal and external appeals)
All insurance providers have an internal long-term disability denial appeal system. What an internal appeal means is that you are requesting the insurance company, which already denied your claim once, to review your claim. Now at this point it should be noted that while insurance companies are bound by the law to honor their policies, it is not in the best financial interest of the company to reverse its original decision.
An internal appeal is generally recommended when the denial is based solely on either a missed doctor’s appointment (which can still be completed), a skipped treatment (which can still be fulfilled), or the insurer requests more medical clarification.
While an internal appeal may seem like an attractive proposition at first, as opposed to pursuing a lawsuit, it does have a major drawback. Not only will an appeal take up a lot of time, but these appeal systems are not regulated. Because there is no Ontario guideline for how long they should take, they can drag on. What this means is that an appeal can take months, and a potential secondary appeal can take even longer. Meanwhile the clock that was started on the original denial is still ticking. With the general limitation on filing personal injury cases being two years, and certain instances which are even shorter, all the delays in the internal appeals process might take away your chance to start an action against the insurer.
Making an external appeal refers to starting an action against the insurer. This means that you are taking your appeal out of the internal mechanisms, created by the insurance company, and are having a neutral third party adjudicate your case.
This is already better than an internal appeal, as the neutral third party deciding your case does not have any inclination to support the insurer. Most often the external appeal process takes place in the Canadian Court system.
An external appeal is highly recommended when you have already been examined by the company doctor (because they will not reverse a decision if they have medical evidence they can rely on), they argue that you are not receiving proper and regular medical treatments, or they denied you based on a technicality (such as a missed deadlines or pre-existing condition).
Now while an external appeal has the benefit of impartiality, such as a trained judiciary, a highly organized process, and the ability to decide on highly complex cases, it also has one major drawback: the sheer complexity of the system. This can be very difficult to navigate which might end in a judge or jury trial. It is at this point where it is highly recommended that you engage with a lawyer to represent you. They will be able to help you organize your evidence, follow the many rules of procedure, and best present your case.
On an appeal to the courts not only can you make a claim for future long-term disability benefits, but also for past benefits you are owed (from the date of the original denial), punitive damages, and compensation for the mental stress that you have suffered.
While it is understandable that many people feel they want to exhaust every internal avenue, before commencing an external appeal, time is the ultimate factor. Deadlines are set the moment the denial letter is issued, and once they pass you may be left with no way of recovering money for your disability. That is why hiring a lawyer as soon as possible is always recommended. They can not only represent you, should you decide to pursue an external appeal, but they can also review the terms of your policy, and the denial, and give you advice on what avenue of appeal is the best for you.
