Why Long-Term Disability Claims Get Denied by Insurance Companies

Injuries and illnesses happen to everyone. But what if someone is severely injured in an accident that requires months of full-time medical care or develops a condition so overwhelming that they can no longer perform routine tasks?

Many employer and self-provided insurance policies include long-term disability coverage that offers benefits to workers in those situations. However, there are times when accessing them can be far from straightforward. Thankfully, there are ways to protect your rights and get the financial support you or your employer paid for when you need it most.

A long-term disability lawyer in Toronto knows the claims process, how to deal with insurance companies and, most importantly, knows the law. They help level the playing field and keep insurance companies honest when they wrongfully deny claims.

Keep reading to discover why long-term disability claims are denied by insurance companies and what you can do about it.

Disclaimer: The information in this guide and everywhere else on this website is for general information only and is not intended to provide legal advice of any kind. No lawyer-client relationship is created by accessing or otherwise using Ertl Lawyers’ website or by communicating with a lawyer or staff member. If you need legal advice, please contact our staff at Ertl Lawyers. We’re more than happy to speak with you.

Types of Long-Term Disability Claims

A long-term disability claim can be made for most illnesses and injuries if they are severe enough to prevent an insured person from performing a substantial portion of their work duties. An injury or illness does not have to be work-related for you to qualify. However, your policy may exclude certain illnesses, so confirm that your condition is covered first if you are considering making a claim. Common causes of disability include:

• Car accidents and personal injuries
• Degenerative disk disease and back injuries
• Fibromyalgia
• Carpal tunnel syndrome, tendonitis and arthritis
• Hypertension and heart disease
• Mood disorders
• Depression, anxiety, PTSD and other mental and behavioural disorders
• Cancer and tumours
• Crohn’s disease and other digestive disorders
• Diabetes
• Chronic pain and fatigue

Check out these disability claims case studies to learn how we help clients suffering from common disabilities get the benefits they are entitled to despite an initial denial by their insurance companies.

If you feel you need to apply for LTD benefits but are unsure if you have a claim, we offer free case assessments and can review your insurance policy to let you know if you qualify. We also offer application services. Based on our experience handling LTD claims, we know what supporting evidence insurance companies require and how to package your claim for the best chance of getting it approved.

Why Long-Term Disability Claims Get Denied by Insurance Companies

Insurance companies routinely deny long-term disability claims the first time around, causing many applicants to give up feeling that there’s nothing more they can do – especially if they’ve submitted the most thorough application they can.

It’s important not to get discouraged and remember that it’s in the insurance company’s best interest to make it seem like the reason for their denial is airtight and there is no point in appealing the decision.

If your claim is denied for any reason, contact an employment lawyer right away. You can also look into government-sponsored support programs on our disability claims resources page for benefits you may qualify for.

If your LTD application was denied, it was likely for one of the following reasons:

Application Filed After the Deadline

Insurance policies often contain a time limit for when a claim can be submitted that begins on the date of disability. Insurance companies argue that it’s harder for them to manage late claims, which is why they have deadlines. If you file your claim after the time limit has passed, they can deny it based on this reason alone. However, you may have a legitimate reason for filing past the time limit that can be argued in a formal appeal or legal proceeding to have the denial reversed.

Exclusion or Ineligibility Because of a Pre-Existing Condition

Long-term disability policies also include clauses that describe situations that make someone ineligible for benefits or coverage. One of the most common used to deny LTD benefits is the clause regarding pre-existing conditions. When using this clause, the insurance company’s denial will assert that the start of your disability, such as the first symptoms, began before the date you became insured and that you are therefore ineligible for benefits or that you made misrepresentations on their claims forms by not including information about your pre-existing medical condition.

To justify this reason for denial, they may rely on symptoms you previously experienced related to a different medical condition or a subjective opinion on when your disability began instead of when you first became aware of the illness or injury in question.

A Lack of Medical Evidence to Support Your Claim

This is one of the most common reasons for denying a long-term disability claim. The insurance company will state that the disability you are claiming hasn’t been proven by the medical documentation submitted with your claim.

This could be because you or your healthcare provider neglected to include a medical record or test with your application. But it is often the case that claims are denied for this reason when they are based on illnesses or medical conditions that can’t be diagnosed or measured with “objective evidence” such as blood tests, MRIs, x-rays, etc. Examples of these illnesses include:

• Depression, anxiety, mood disorders and other mental illnesses
• Fibromyalgia
• IBS
• Chronic fatigue or pain

In other words, an insurance company will deny an application based on an illness or condition because of a lack of proof when there is no way to prove the severity of the symptoms aside from what you tell your doctor about how you feel. Many insurance policies, however, do not actually require “objective evidence,” and an experienced disability lawyer knows how to push back against these types of denials. It’s a good idea to keep a pain journal and document when you experience a symptom, how painful it was and its effect on you to assist with your treatment and your claim.

You can also be denied for lack of medical evidence even if you submit tests, diagnostic imaging, etc. The insurance company may simply conclude that what you submitted doesn’t sufficiently prove the disability claimed based on their interpretation of the medical records.

Your Illness or Injury Isn’t Considered a Disability

Similar to a lack of medical evidence, insurance companies often justify a denial by claiming that the documentation in your application doesn’t support a finding that you are disabled by your illness or injury.

Policies commonly use the term “totally disabled” as the criteria for qualifying for long-term disability benefits. However, the standard for meeting the requirements of a disability claim is that your condition prevents you from performing a substantial portion of your job duties.

The insurance company will either claim that your application failed to directly show how your symptoms prevent you from performing specific aspects of your job or that their medical professional’s assessment shows that your condition isn’t severe enough to prevent you from working if you’re provided with suitable accommodations.

For example, if you work in an office and are disabled by arthritis or carpal tunnel syndrome, the insurance company may take the position that you can continue working since your work is sedentary and your employer can provide speech-to-text software or other accommodations if needed.

Failing to Comply with Treatment or Insurance Policy Requirements

The insurance policy may require that you meet with a medical examiner chosen by the insurer for an “independent medical examination (IME)” during the application and/or at regular intervals if you’ve been approved for LTD benefits. While IMEs are often designed as an opportunity to deny benefits, it’s better to attend them and dispute the decision later than not to show up at all. Failing to attend will likely result in a denial or stoppage of benefits.

Insurance companies also deny or stop benefits if you do not follow a treatment or rehabilitation plan they design for you or one created by your doctor. Attending your healthcare appointments and following your treatment plan is crucial for your health and the success of your claim.

If you are unable to keep up with the insurance company’s treatment plan, let your doctor know and speak to a disability lawyer immediately.

You Are No Longer Disabled

If your application is approved and you receive LTD benefits, the insurance company may stop those payments by claiming that you are no longer disabled. They can base this decision on information reported during an IME or conditions included in the policy.

When your LTD application was approved, the insurance company conceded that you met the requirements for being disabled because you were unable to perform the tasks of your current job or your “own occupation.” However, most policies will change the eligibility for LTD benefits after a specific period of time, usually two years. At that point, the requirement to remain eligible for LTD benefits is that your disability prevents you from performing the essential tasks of “any occupation” that you could reasonably perform with training, not just the job you were doing when you became disabled.

Contact a disability lawyer immediately if you receive notice that your benefits are being stopped.

The Insurance Company Has Evidence that Contradicts Your Claim

Insurance companies often employ investigators to conduct surveillance on long-term disability claimants and those already receiving benefits. That surveillance can include following the insured and taking pictures or videos of them when they leave their home, checking their social media accounts and running driver’s licence and internet searches.

Their goal is to gather evidence that shows that you are not as disabled as you claim. That evidence can include:

• Pictures or video of you carrying groceries, playing with your children or doing any physical activity if your claim is based on a physical disability.
• Social media posts that show you celebrating with friends, on vacation or exercising to make it look as though your mental or physical disability isn’t as severe as you claimed.
• Anything that comes up in a court case database, license or Google search that shows you as a “professional plaintiff” or someone who is constantly filing lawsuits and claiming injuries.

It’s essential to be honest with your doctor or specialist at all times and remember that you can be followed and photographed anytime you are out in public. Surveillance can be used as an intimidation tactic by the insurance company but be careful – people have been wrongly accused of fraud based on video surveillance.

What to Do If Your Long-Term Disability Claim is Denied or Your Benefits are Stopped

Speak to a long-term disability lawyer immediately if your claim is denied or you receive notice that your benefits are being stopped. You have the option to appeal through the insurance company’s appeal process or to file a lawsuit but both options have time limits. LTD lawyers know the best route to take based on the reasons for the denial, and your appeal stands a better chance of success with an expert who knows the system.

We provide a free, no-obligation disability policy analysis and case assessment when you book a consultation. You’ll get an honest, professional opinion on how strong a claim you have and the best way to get it approved or to fight your denial. We offer fair and flexible pricing, including contingency “don’t pay unless you win” fees.