When A Claim Is Denied

There is nothing more stressful than having your disability benefits denied by your insurance company.

You rely on these benefits to protect you if you can’t work – then you discover that they aren’t there when you need them.

I have represented many people when their short-term disability (or STD) or long-term disability (or LTD) benefits are denied by their group insurance at work.

I want to share with you a bit about your choices when that happens.

There are three moments when insurance companies often deny claims:

First, when you first apply for short-term disability (or STD) benefits;

Second, when you apply to move onto long-term disability (or LTD) benefits after 6 months or so; or

Third, when two years pass, and the insurance company says that you may not be able to go back to your old job, but maybe there’s some other job that you should be able to do.

THE CHANGE OF DEFINITION DATE

This two-year mark is called “the change of definition” date and it’s a day when the test for receiving benefits – what it means to be disabled – changes, sometimes making it harder to qualify for benefits. But it doesn’t have to mean the end of your benefits.

When the insurance company denies your claim, they will give you an opportunity to ask them to reconsider their decision.

They may call this an “appeal,” but unlike when lawyers appeal a court decision, there is no higher court that you’re appealing to – you are just asking the insurance company to change its mind.

I’m sorry to say that they usually don’t change their mind.

In most cases, they will stand by their initial decision, even if you supply new medical evidence to support your claim, like a letter from your doctor.

Your case is delayed while you try to gather new medical information and they review the things you send them.

Sometimes people try appealing two, three or even more times, and the clock keeps ticking.

This ticking clock matters to you, because all this time you and your family are living without your benefits and the pressure to go back to work keeps getting higher and higher, even if you’re not ready and it would be harmful to your recovery.

You might feel you have no choice.

TWO-YEAR LIMITATION PERIOD

Plus, there’s a two-year limitation period in Ontario for suing your insurance company – if that time passes, you may be out of legal options entirely.

So it might not surprise you that my advice is to call a lawyer who specializes in disability claims right away, when you get that letter from the insurance company saying that they’re denying or cutting off your benefits.

Most disability lawyers like me don’t charge for an initial consultation.

A lawyer who specializes in disability claims will hear you out and discuss your options with you, so you can make an informed decision about appealing the insurance company’s decision or suing them.

We can also point you to other benefits you may be able to access to take the pressure off, like CPP Disability from the federal government and, in some cases, WSIB benefits funded by your employer. And they can help you decide whether to appeal or sue.

You don’t need to figure this out by yourself. It seems complicated but it honestly doesn’t have to be.

It’s about finding the best way of ensuring that the insurance company lives up to its obligations to you and your family, so you have the space to do what you need to do to get better.

Our video series is designed to shed some light on personal injury and disability law and provide the insights you need to make an informed decision about what is best for you and your loved ones.

Be sure to watch the other videos in our Personal Injury Explained series.