In Canada, just like anywhere else, you can be denied long term disability benefits. Sometimes the insurance company or Canada Pension Plan disability officials have very valid reasons, other times not. The insurance sector is very unique because it involves pulling together resources from a large number of people for collective protection from risk of loss. The insurer will make a profit if the amount it pays out is less than the amount you and other insured persons contribute to the pool. The insurer is therefore justified to be vigilant and reject any claim that is not well proved. However, sometimes the desire to make huge profits pushes insurance companies to deny even the most legitimate claims. Therefore, you need to know how to avoid instances that can give a leeway to your insurer to deny your claim. You should also be equipped to deal with any possible unjustified denial.
Why Would Your Insurer Deny Your Claim?
There are mistakes and omissions that can make your insurance company deny your long term disability claim. Here are some reasons:
Failure to Provide Sufficient Medical Evidence
To have your long term disability claim approved, you need supporting medical evidence including the following:
- Your Physician’s Statement. Your physician’s statement is critical in proving your disability claim. You should request your treating physician to make a detailed statement as to your health and how your condition makes it impossible for you to work. You should not rely on the forms from your insurer because they are tricky with the aim of eliciting responses that support a denial. If your treating doctor is not willing to support your case, you should consider consulting another one.
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Evidence of Regular Medical Treatment. In addition to your doctor’s report that details your disability and how it limits your ability to work, you should also have documents to show that you have attended medical treatment regularly. If you do not prove that you have had regular medical treatments, you are likely to be denied for your long term disability benefits. Your insurer expects you to make regular visits to your physician as well as a specialist. For example, if the cause of your disability is related to depression, anxiety or any similar psychiatric disorder, you should be seeing a mental health practitioner such as a psychologist or psychiatrist every month. Every time you visit, your doctor should give you objective tests including MRIs, CT scans and X-rays where applicable.
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Never Have Missing Records. If you fail to submit all your medical records to the insurance company, you will likely get a denial. Before submitting the documents, ask the company to give you a list of the documents that should accompany the application. When submitting them, you should have a forwarding letter and have your insurer’s representative sign on a duplicate of the letter acknowledging that they have received all the documents. This should serve as evidence that you submitted all the documents, in case the insurer misplaces some of them. Additionally, make sure you make copies of all the documents submitted and keep them safe, they will help you in case of a denial.
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Failure to Meet the Definition of Disability. Your policy will always define the scope of coverage including the definition of disability. Usually, you will be disabled under a policy if you are unable to perform the duties of your particular occupation. However, the criteria changes after some months so that you are disabled only if you cannot perform the duties of any gainful employment. Before you submit your application you should ensure that your medical report meets the definition of disability under your policy. You should also check your policy to ensure that your disability is not related to an excluded condition.
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Acting in a Manner Inconsistent with Your Disability. Your insurer may send its agents to take video surveillance on you. If the video captures you doing anything inconsistent with your disability, your claim may be denied or terminated if you had already been approved. The best thing is to act as advised by your physician.
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Missing Deadlines. If you get disabled, find out from your insurer any deadlines in application and appeal processes. It is advisable to engage a long term disability lawyer familiar with the process.
What Should You do if Your Long Term Disability Application is Denied?
Receiving a denial letter is one of the most discouraging things that can happen to you when you are disabled. You may have placed all your hope for financial support in the long term disability benefits. However, you should not despair just because you have received a denial. You still have the options of filing an internal appeal or suing the insurance company.
How to Write a Long Term Disability Appeal Letter
- Read and understand your denial letter
- Request for your claim file
- Read and understand your insurance policy
- Collect all documents that you need to prove your case
- Compose your disability appeal and file within timelines.
