Long-term disability insurance performs a critical function for hardworking Canadians who have to leave their chosen careers sooner than they would have preferred, due to an untimely illness or injury. The unfortunate reality, however, is that private LTD companies like Manulife have a strong profit motive to deny claims whenever possible. Sometimes this means that a valid long-term disability claim gets denied. The TSF Law team has experience handling long-term disability appeals throughout Canada, and we are prepared to listen to your situation and provide answers to pressing legal questions. Contact our office in Orangeville, Ontario, without hesitation. Call (905) 218-3668 today.
Is It Possible To Fight a Denied LTD Claim?
Manulife is one of the largest insurers in Canada offering long-term disability (LTD) coverage. Like many other insurers, Manulife routinely denies LTD claims, so if your claim for Manulife long-term disability has been denied, you have plenty of company.
Summary of LTD Claims and Manulife Insurance Plans
Manulife LTD claim denials commonly involve alleged pre-existing conditions, insufficient impairment, insufficient medical evidence, or disputes regarding own-occupation versus any-occupation policy definitions. Private long-term disability insurance policies are governed by contract law, while provincial insurance regulators, such as the Financial Services Regulatory Authority of Ontario, oversee insurer conduct within their jurisdictions. Reviewing the insurance policy, denial letter, supporting medical documentation, and applicable provincial insurance rules may help individuals prepare an LTD appeal supported by additional evidence. TSF Law provides legal services related to long-term disability claim denials and appeals for individuals across Canada, including Ontario, Alberta, and Nova Scotia.
What Are the Most Common Reasons for LTD Denials?
Fortunately, many LTD claim denials can be resolved through appeals. The specific strategies a Manulife long-term disability claim may need will depend on the exact reason why the claim was denied, but a quick look at some of the most common reasons we see and the ways individuals successfully fight back may help start the process.
Pre-Existing Conditions
Even if the onset of symptoms is relatively recent, it is not uncommon for insurers reviewing LTD claims to allege that a policyholder’s disability actually results from a pre-existing condition. Pre-existing conditions tend to be excluded from coverage under the terms of most private long-term disability insurance policies, so if the insurance adjuster reviewing your claim can find any justification for linking the current disability to a condition established within the “lookback” period used to identify pre-existing conditions, they will often do so. This means that you may have to shoulder the burden of proof for showing that the current disability is a genuinely new condition.
Insufficient Impairment
Another very common reason long-term disability insurance providers cite for denying claims is that the individual seeking to claim their LTD benefits is not disabled enough to qualify. What “enough” looks like will be determined by the terms set out in the specific policy, so there is no single standard that applies to all cases. Generally, however, private long-term disability plans may be divided into two main categories: own occupation and any occupation. Importantly, many LTD policies offer a limited period of own-occupation coverage (based on whether the condition restricts you from continuing in the profession you were in before becoming disabled), and then transition to any-occupation coverage (based on whether you can return to work in any role) after a contractually specified period of time; a two-year period is common, but policies vary.
Job Role and Limiting Symptoms
The specific mental and physical demands of maintaining employment can differ dramatically from one profession to another, and even between roles within a single field. Individuals on long-term disability have to consider not just “how disabled” they are in an abstract sense, but the concrete fit between the demands of a particular role and their own specific limitations. A set of symptoms that make one job totally impractical might have little to no effect on how capable the same person would be of fulfilling the responsibilities associated with another position.
Calibrating An Appeal to Your Circumstances
Individuals on LTD policies that are determined on an any-occupation basis from the start may face initial denials based on the insurance company’s claim that the policyholder is actually able to work, even though they might have to change jobs and even industries. Depending on the terms of the policy, however, even individuals who are initially approved for benefits may be denied continuation if their policy contains a clause specifying transition from own to any occupation. Many Manulife LTD recipients may find themselves needing to prove their disability to a new standard once their initial own-occupation period ends.
Insufficient Evidence
Insufficient evidence is not quite the same as insufficient impairment; while both do ultimately relate to whether a claimant has proven “enough,” a denial based on insufficient impairment generally means that the evidence submitted does not show a condition severe enough to warrant approving the claim, while an insufficient evidence denial means the insurance adjuster did not find enough evidence of a disabling condition. Depending on the exact parameters of the policy and the claim denied, there may or may not be more than “mere” semantics in the distinction.
How To Fight a Denied Long-Term Disability Claim
If Manulife denies a long-term disability claim that you filed in good faith and still believe to be legitimate, you may want to appeal that denial. Every situation will come with its own challenges, but there are a few general guidelines that may help prepare to fight back.
Review the Policy
Private long-term disability claims in Canada generally belong to the territory of contract law. The insurance policy essentially functions as a set of contractual terms setting out what the insurance company promises to do (provide income replacement benefits in response to a claim) and under what conditions (once the claimant has submitted sufficient evidence of a qualifying condition in the format required by the insurance provider and within the designated window for filing a claim).
The essence of the first part usually will not change very much from case to case, although there will be considerable variance in the amount of the payout and the percentage of the policyholder’s pre-disability income it represents. Instead, the conditions that bind the insurer to “perform” their contractual obligation by paying LTD benefits will often be the area of focus, because the exact wording used in the policy establishes what the insurance provider is allowed to demand from you in terms of evidence, as well as the procedures to follow to appeal a denied claim.
Establish Legal Context
Although the terms of the policy will set out Manulife’s contractual obligations, jurisdiction will determine the legal framework within which those terms are to be interpreted. There are two levels of legal apparatus to be concerned with here: the general principles of contract law, which as we said before will typically apply because an insurance policy functions as a contractual agreement between an insurance provider and the party who purchases a policy; and insurance regulations, which in Canada tend to be decided by the provincial and territorial governments, and overseen by their respective regulatory authorities.
The Financial Services Regulatory Authority of Ontario (FSRA), for instance, is responsible for supervising the practices of private insurers throughout the province in accordance with the Conduct of Insurance Business and Fair Treatment of Customers guidance document adopted by the Canadian Council of Insurance Regulators (CCIR) jointly with the Canadian Insurance Services Regulatory Organization (CISRO). Although CCIR and CISRO are obviously national in character, the way their principles are applied and the way their guidance is administered by provincial and territorial authorities mean that you may find it helpful to review the terms of your LTD policy, along with your denial letter from Manulife, with a lawyer in your area.
Review the Denial Letter
Because there is usually little question what the insurance provider in a long-term disability claim has pledged to do, under the terms of the policy, denial letters will typically frame the insurance company’s rejection of the LTD claim in terms of the conditions and exclusions that delineate when the contractual obligation to pay benefits will apply. The specificity of the denial letter and the degree of precision with which it spells out the steps to take to appeal the denial may depend partly on what practices are treated as fair practices under the insurance regulations in your area; the language used by insurance companies may not always be immediately transparent to individuals not used to processing this type of document, so sorting through the appeal requirements is another reason it can be often be helpful to talk with a lawyer once you have your denial letter in hand. At TSF Law, we welcome inquiries from long-term disability claimants nationwide, but we are especially experienced in LTD cases from Alberta, Nova Scotia, and Ontario.
Review Documentation
Even allowing for significant variations in the type and extent of evidence you may need to appeal, based on the reason given for the initial denial of the claim, almost all LTD denial challenges involve collecting, organizing, and submitting additional documentation of some kind. Common examples of supplementary documentation you might need to file with an appeal include:
- Letters from your physician
- Granular explanation of limitations (not symptoms)
- The results of medical tests or scans substantiating the physiological cause of the limitations you claim
Other forms of documentation may also be appropriate, depending on the case.
Talk With a Long-Term Disability Lawyer Near You
Our TSF Law team is based in Ontario, but we regularly handle long-term disability cases from across Canada, and we have extensive experience with LTD cases in Nova Scotia and Alberta. If your Manulife long-term disability claim has been denied, take your first step toward fighting back by calling our office at (905) 218-3668 today.
Frequently Asked Questions About Manulife Long-Term Disability Claims in Canada
The following frequently asked questions address common legal issues involving Manulife long-term disability claims, LTD claim denials, insurance policies, and the appeals process in Canada.
Why Does Manulife Deny Long-Term Disability Claims?
Manulife may deny a long-term disability claim when the insurer determines that the claim does not satisfy the insurance policy’s contractual requirements. Common reasons include alleged pre-existing conditions, insufficient medical documentation, disagreements regarding disability severity, or conclusions that the claimant remains capable of working under the policy’s own-occupation or any-occupation definition.
Can A Denied Manulife Long-Term Disability Claim Be Appealed?
Yes, many denied Manulife long-term disability claims may be appealed if additional evidence or legal arguments address the reasons identified in the denial letter. The appeals process often involves reviewing the insurance policy, gathering supplemental medical documentation, responding to the insurer’s stated concerns, and complying with applicable deadlines established by the policy or governing legal framework.
What Is The Difference Between Own-Occupation And Any-Occupation Disability Coverage?
Own-occupation disability coverage generally evaluates whether a medical condition prevents performance of the claimant’s regular occupation, while any-occupation coverage considers the ability to perform other suitable work. Many Canadian long-term disability policies transition from own-occupation coverage to any-occupation coverage after a specified period, which may change the standard used to evaluate continuing eligibility for benefits.
What Evidence Is Commonly Needed To Appeal A Long-Term Disability Claim?
A successful long-term disability appeal often requires medical evidence that clearly documents functional limitations, diagnoses, treatment, and the connection between the medical condition and work restrictions. Supporting documentation may include physician reports, diagnostic testing, specialist evaluations, and detailed explanations describing how specific physical or cognitive limitations affect occupational duties.
What Should Be Reviewed After Receiving A Long-Term Disability Denial Letter?
A long-term disability denial letter should be reviewed carefully because it typically explains the insurer’s reasons for denying benefits and identifies relevant policy provisions. Comparing the denial letter with the insurance policy, medical records, and supporting documentation may help determine what additional evidence or clarification could be relevant during an appeal.
How May TSF Law Assist With A Denied Manulife Long-Term Disability Claim?
Individuals with a denied Manulife long-term disability claim may consider visiting with an experienced attorney at TSF Law to better understand available legal options and the appeals process. The team at TSF Law works to help individuals understand their insurance policy, review denial letters, evaluate supporting medical documentation, and clarify potential legal paths for long-term disability claims across Canada.
