You are disabled and cannot work. Your workplace provides Long Term Disability (LTD) coverage as part of your health benefits package. If you are unable to work for health reasons, the LTD insurance benefits coverage should provide you with income protection while you are unable to work for reasons related to your illness or disability. Unfortunately, individuals are often denied LTD benefits for reasons which are often all too common. Here are the Top 5 reasons we have seen in our practice:
1. Insufficient medical evidence
Despite the fact that you and your doctor have filled out the required forms and provided access to your medical file, the insurance company may deny your claim because the medical documents you provided do not support your claim that you are unable to work due to illness or disability. Yet, the insurance company is unlikely to explain why the documents are insufficient. With the support of your family doctor or other treating physician, you can provide additional evidence in support of your claim.
2. You do not meet the policy’s definition of “total disability”
Each long-term disability insurance policy defines what it means to be “totally disabled”. At first glance, it might seem like an insurmountable threshold to attain, however, what it usually means is that a person cannot perform the usual duties and responsibilities of their own occupation. By stating that you do not meet the definition of “total disability”, the insurance company believes that you can work. If your treating physician’s opinion is that you cannot work, you can contest this denial.
3. You can work in another occupation
Many individuals who are in receipt of LTD benefits are cut-off after 2 years as this is usually when the definition of “total disability” in the insurance policy changes. For the first two years you have to be unable to work at your own job. But after two years, most policies state that being “totally disabled” means being unable to work in any occupation, usually another occupation for which an employee is qualified or can easily become qualified. There are often differences between policies but the insurance company takes the position at this point that an individual can work in another occupation and therefore is no longer “totally disabled”. If your treating physician advises that you cannot work in any occupation and the insurance company does not accept their medical opinion, you can contest their decision.
4. You have an excluded or pre-existing medical condition
Some insurance policies may exclude certain conditions, deny coverage for pre-existing medical condition or have a waiting period for claims due to a pre-existing medical condition. It is important to review the policy to see if and when you are covered for pre-existing medical conditions. If you are denied coverage due to a non-disclosed pre-existing condition, this can also be reviewed depending on the context.
5. Lack of “objective medical evidence”
Individuals with invisible disabilities such as mental health conditions, fibromyalgia, chronic pain, chronic fatigue syndrome are often denied due to lack of “objective medical evidence”. These diagnoses are often based on self-reported symptoms and their effect on the individual’s activities of daily living. Insurance companies often deny these claims because there is no official test, or diagnostic image to confirm the existence of the illness or disease. Once again, a denial in these circumstances can be successfully contested.
Other reasons such as a failure to meet a deadline or the insurance companies’ reliance on an internal medical consultant’s opinion can also be used as excuses to deny LTD benefits. If any of the above reasons are cited in the decision to deny or stop paying your LTD benefits, we strongly recommend you contact a lawyer in order to discuss next steps.
Note: This article is for informational purposes only and does not constitute legal advice, which requires an assessment of your individual circumstances.]