Long-Term Disability Claims – What You Need to Know

Some illnesses or injuries can leave you debilitated and unable to work. In a worst-case scenario, recovery can last months, or even years. To help cover you during this time, many insurance companies offer long-term disability benefits, which are often included as part of an employment benefits package.

Whether you are eligible to make a long-term disability claim depends on whether you satisfy a condition called “total disability”found in each policy – this means that you are unable, due to your injury or illness, to fulfill the normal duties of your regular occupation. This does not require you to be completely incapacitated in all ways. It does, however, require that for you to recover, you must not be able to work in your occupation. This also includes any occupation for which you might be suited.

To determine if you meet the requirements of “total disability,” your insurance company may require independent medical examinations to be undertaken. Once these examinations indicate that you will be disabled for months or years, you qualify for a long-term disability claim.

Long-term disability provides a portion of your salary until you can return to work. This is different than WSIB insurance, which only covers accidents and injuries that take place on the job – disability insurance covers any injury or illness that prevents you from working, regardless of where or when it occurs. As Employment Insurance (EI) covers the first 119 days, most long-term disability policies only begin their coverage on day 120. Some workers will have access to short-term disability benefits to cover this waiting period before long-term disability benefits commence.

While this coverage can last as long as to the age of 65, this is not universal. Many long-term disability recipients are re-evaluated after two years – at that time, the definition for “total disability” often changes and becomes more difficult to meet.

There are a number of reasons why a long-term disability insurer might deny a long term disability claim, many of which can be contested in court. These include:

• Lack of “objective” evidence of disability. This means that the insurance company could not measure through an objective means how much pain you are suffering, or that it is indeed debilitating. Since pain is often subjective, and often cannot be measured in an objective fashion, this can be a grounds for dispute.
• Lack of your injury restricting or limiting your ability to do your job. This means that in the insurance company’s assessment, your injury or illness does not actually render you as having a “total disability”. This can also be a source of error, especially if the insurance company is not working off of an accurate job description, or lacks an understanding of the subtleties of your job.
• After conducting surveillance, the insurance company does not believe that you are as disabled as you claim. While surveillance can be an important step in preventing insurance fraud, it can also be fallible as it does not necessarily present a complete picture.

If your claim has been wrongfully denied, it is very important to consult a personal injury or disability lawyer as soon as possible, before entering into an appeals process. All claims are subject to a statute of limitations, usually of two years from the incident or wrongdoing, after which time it is too late to file a claim or lawsuit. Therefore, it is often better to hire a lawyer and file a disability lawsuit instead of undergoing the appeals process.

While you are going through the process of making a claim with the insurance company or dealing with a rejected claim, if your injury or illness is severe enough there is also community assistance to help you with your recovery (assuming you have no other access to other kinds of insurance coverage such as motor vehicle coverage). Established in 1996, Ontario’s Community Care Access Centres (CCAC) exist to provide aid and assistance to those in need, including people disabled from injuries. This includes identifying your needs, helping you get onto an appropriate waiting list for treatment or care, and helping you find financial aid while you recover. Unfortunately, the CCACs are often underfunded, leaving them unable to provide comprehensive support or service, and are not a substitute for a proper rehabilitation program.

In the end, receiving regular, consistent long-term disability can be a vital tool in helping you get through a debilitating illness or injury. Knowing how disability coverage works – and how to successfully dispute a claim that has been denied if it becomes necessary – can help you get the coverage that best helps your recovery.