What To Do If You Have Been Denied
If your Long Term Disability Insurance (LTD) benefits have been denied, you are likely under a lot of stress. It does not help that this area is plagued with contingencies and ambiguities that can, and often do, send claimants on a wild goose chase. This article is meant to assist you with your Long Term Disability claim by first educating you on the basics of Long Term Disability benefits, and then guiding you on how to build your case, and what to do if you have been denied.
When speaking about Long Term Disability Benefits, each and every case is different, and the law around Long Term Disability is complex. The information in this article is provided for informational purposes only, and is meant to be general in nature. No Solicitor Client relationship has been established from the use of the information. If your benefits have been denied, and you are interested in legal assistance as it pertains to your particular case, Murray Ralston is more than happy to offer you a free consultation.
Long Term Disability Benefits: An Overview
Long Term Disability Insurance is designed to provide replacement income in the event that one suffers from an illness or injury that prevents them from working for a long period of time. Generally speaking, in order to be eligible for Long Term Disability benefits, you must be suffering from a medical condition, illness or injury that your insurance company believes has rendered you unable to do your job. It is important to keep in mind that, what is covered under your Long Term Disability insurance varies from policy to policy, and it is best to review your policy; or if you are covered under a group insurance plan, review the benefits booklet provided to you by your employer.
Long Term Disability Claims: Precautionary Steps to Take
It is important to act proactively to ensure you do not give your insurance company a reason to deny you. The following are the necessary precautionary steps you should be taking when applying for your Long Term Disability benefits:
Check & Meet Deadlines: Do not give your insurance company a reason to deny you. Read your policy for timelines and deadlines very carefully. Policies typically state certain deadlines and qualifying periods. Ensure that you meet these timelines, and if not, that you are in communication with the insurance company about any required extensions. These communications should be documented.
See a Doctor: As soon as you find yourself in pain or in a situation where you are injured or have some medical condition, you must see your family doctor. This is a crucial step, both for your health and for your case. Remember, your qualifying for benefits depends on whether the insurance company believes that your medical condition has rendered you unable to work. Seeing a doctor about your condition, and having a doctor’s report, forms the foundation of your lawsuit.
Request Long Term Disability Application from Employer ASAP: Immediately request the Long Term Disability application package from your employer. This package requires you, your employer, and your doctor to fill out certain forms. Again, do not give the insurance company a reason to deny you. Be diligent about getting these forms completed and submitted on time.
Read Policy in order to determine what is required to qualify for benefits: Fourth, remember to read your policy very carefully about what is required in order to qualify for benefits.
What is meant by ‘Disability’: Check your policy’s summary plan description for the precise definition of ‘disability’ to see if you can meet it. For instance, under an ‘own occupation’ Long Term Disability policy, you are disabled if you are medically unable to do the tasks associated with your particular occupation. There are also “any occupation” Long Term Disability policy’s, which mean that you must be totally or substantially disabled from the duties of any occupation for which you have the requisite education, skills or experience. There are some Long Term Disability policies that start off as ‘own occupation’ and transition into ‘any occupation’ after a certain time period has lapsed. It is important to check your policy to determine what exactly is meant by ‘disability’ and what criteria must be met in order for you to qualify.
“Excluded Medical Conditions”: Also, you must check your policy’s summary plan description for excluded medical conditions (ie. medical impairments related to substance abuse or pre-existing conditions are typically excluded from coverage). There are some policies which may exclude conditions based on subjective complaints rather than objective testing, or limit coverage to a certain period of time (ie. depression, chronic fatigue syndrome, and fibromyalgia).
REASONS FOR THE DENIAL OF YOUR LONG TERM DISABILITY INSURANCE BENEFITS:
There are several different reasons for being denied your Long Term Disability benefits:
Insufficient Medical Evidence:
Undergo Regular Medical Treatment and Check-Ups: Having supportive medical records is a crucial component of your Long Term Disability benefits case. Your insurer will expect you to make visits to your family physician and appropriate specialists at regular intervals. You have a duty to behave responsibly and mitigate your damages. You are expected to look after yourself by getting the medical attention you need and by sticking to the plan of care set out by your doctor. Often, the insurance company will want medical documentation to this effect. This medical documentation should be updated regularly (i.e. Regular visits to your doctor to monitor any changes in your condition).
Ensure Insurer has All Medical Evidence: Sometimes, disability claims are denied due to insufficient medical evidence simply due to the fact that the insurance did not receive all your medical records. Make sure you request from your insurance company what documents they have in their possession, and what documents they have requested. Determine which documents, if any, are missing, and take active steps to ensure your insurer makes the appropriate requests.
Obtain Doctor’s Opinion: A very critical component of your Long Term Disability case lies within obtaining from your treating physician, a detailed opinion pertaining to your medical condition and the ways in which it affects your ability to work. Although the insurance company does have forms completed by your doctor in order to make this determination, one should not rely solely on these forms. Often times these forms are not designed to elicit favourable responses, which tend to have a negative impact on ones Long Term disability benefits claim. You or your lawyer should ask your treating physician for a report that details exactly how your medical condition prevents you from performing activities associated with doing your job. If your doctor will not help you, seek out another doctor.
Generally speaking, if a company can prove that you had medical conditions that affected your ability to work or were related to your current medical conditions, prior to taking the policy, the policy can be voided.
Failure to meet Policy’s definition of ‘disability’:
The most common reason why insurance companies deny claims is because of the insurance company’s belief that you fail to meet the current definition of disability. As explained above in this article, check your policy thoroughly for definitions of ‘disability’ and stipulated criteria on what is required in order to be considered ‘disabled’.
If all documentation required to make a claim is not sent to the insurance company in a timely manner, then the claim may be denied.
Fraud or Misrepresentation:
You may initially be tempted to omit certain information because you are afraid that if you disclose that information, you will be denied benefits. Any misrepresentation of yourself while filling out the insurance application can result in the policy being declared void.
As explained earlier in this article, insurance companies often stipulate in the policy that certain medical conditions are excluded from being covered by the policy, such as substance abuse for example.
Often people do not realize that insurance companies often hire private investigators and rely on surveillance in order to find evidence of whether a person is not fit to work.
Observation / Interviewing: A private investigator may watch, follow, photograph, film and/or interview your neighbor, former co-workers and others to verify the level of activity being reported by the claimant and to weed out potentially fraudulent claims. If you have been dishonest with the insurance company, and have failed to disclose relevant information, this surveillance tactic can hurt your case.
Social Medial: Insurance companies can gain evidence through social media and networking sites like Facebook, Instagram, Twitter etc. A single photograph can discredit you, and taint your case in ways which may not be recoverable. For example, you say you are unable to work due to your condition and then share a picture of you rock climbing. Even if the rock climbing does not aggravate your medical condition, this picture will be damaging to your case. It places doubt in the mind of the insurance company, and that doubt is sufficient to damage your case.
WHAT TO DO IF YOUR LONG TERM DISABILITY CLAIM HAS BEEN DENIED:
Option One: Internal Review Appeal Process
Option Two: Litigation (Suing the insurance company for breach of contract)
Getting that denial letter from the insurance company can be very frustrating. In that denial letter you will have noticed that the insurance company has invited you to appeal their decision using their internal review process. It is important to understand that, while you certainly have the internal review appeal process available to you, this is not necessarily the best option for you, and may even be detrimental to your case. As an alternative to the internal review appeal process, you have the option of suing the insurance company for breach of contract.
Many people miss out on this second option either because they do not realize that they have this option, or because they are under the misconception that they are required to first exhaust the internal review appeal process before commencing litigation and/or they believe that it will cost them more to litigate than to appeal. The following information provides a brief overview of the appeal and litigation process, and what you must know about each before making a decision on which option is best for you. However, this information is meant to be used for informational purposes only, and it is prudent that you consult a lawyer about your case before making any decisions on which direction to go.
Internal review appeal process:
The internal review appeal process is essentially a process whereby you are asking the insurance company to reconsider their decision. It involves sending the insurance company updated information and medical documentation. Often the insurance company will have you assessed and examined by a physician of their choice. An inherent problem with this option is that you are essentially appealing to the same insurance company that denied your claim the first time around. And it is rare that in the face of the same set of circumstances and documentation they will change their mind. Another inherent problem with this option is that in the event that the insurance company has more than one level of appeal (which is often the case) by the time you are through exhausting each level, and exhausting yourself in the process, you will likely have depleted your resources, and your morale.
Thus, while at first glance the internal appeal process appears to be appealing, because it appears you are working with the insurance company to get what you want, as opposed to against it (in the case of litigation), this often works out to be a double edge sword, as it does not necessarily mean that the insurance company is working with you. You are not only delaying your case (by delaying litigation), you may actually be harming your case (by affording the insurance company more time and more chances to collect unfavorable information on you and your medical condition).
LITIGATION: SUING YOUR INSURANCE COMPANY
Long Term Disability benefits are essentially a contract between you and your insurance company – via your employer - where they have promised a certain figure amount for a certain period of time, if you are unable to work due to your medical condition. The Litigation option therefore essentially involves suing the insurance company for breach of that contract. In order to determine whether or not you should sue, you should seek legal advice as soon as your Long Term Disability insurance denies your Long Term Disability insurance claim. There are strict limitation periods associated with Long Term Disability claims and it is very important to take immediate steps to obtain legal advice once you are denied.
2 Year Deadline on Commencing Lawsuit against Insurance Company:
In order to sue the insurance company, you must have commenced legal action against them within 2 years of the date you received the denial letter. There are legal arguments lawyers can make about when exactly the limitation period starts to run such as ‘rolling-limitation periods’, however, the insurance companies usually argue that it begins to run from the date of that first denial letter. It is prudent not to blindly rely on representations made by your insurance company as to whether you still have time to commence legal action against them. Consult with a lawyer to determine what your options are if this representation is being made.
IS LITIGATION EXPENSIVE?
Murray Ralston often works on a contingency basis, which means that, depending on the case, no legal fees are due until compensation has been received. Murray Ralston offers free consultations and is happy to meet with you to discuss your case and ensure that you are well informed about your options before taking any action.
What Documents To Bring Your Lawyer:
In order to assist you with your Long Term Disability insurance benefits claim, your lawyer will require certain information from you and will need to review certain documents, including your insurance policy and claim information, the denial letter (if applicable), a record of all premiums paid towards your benefits, your complete employment file, other income sources, occupational information, a list of health care professionals you have consulted, and diagnostic and treatment information regarding the physical and/or psychological aspects of your disability. Further, your lawyer will need to know the nature of your illness or injury, the symptoms that prevent you from working, when you developed the symptoms, when you stopped working, when you received treatment from a physician, and the tasks required by your occupation and why you are unable to perform them.
Ready to find out more?
If you would like more information or if you have been denied your long term disability benefits claim, let the team at Murray Ralston Lawyers help.
*** The information above is not intended to be legal advice. Each situation is different and the information provided above may not provide you with all law applicable to your facts. To ensure you are properly protected under the law applicable to your facts, please contact Murray Ralston Law for a free consultation.