Our law firm handles a wide variety of Long Term Disability (LTD) Claims against pretty much every deep pocketed insurer you can think of: Manulife, SunLife, Great West Life, Desjardins, SSQ, RBC Insurance, Empire Life, Canada Life, Industrial Alliance, Equitable Life, Co-Operators, Standard Life (Now Manulife). If you can name them, we have probably sued them.
Although every LTD claim is different, and every insurer handles claims in their own way, our lawyers see many similarities for these denied claims. Because we have years of experience helping people get the benefits they deserve, we are able to share some of our wisdom with you, our readers of the Toronto Injury Lawyer Blog.
For today’s instalment, we would like you share with some of the top reasons why Long Term Disability Insurers deny claims.
When assessing your LTD claim, it’s important to take a step back for a moment and understand the nature of insurance companies. An insurance company is generally a large, publicly traded, multi-national corporation. Their shares trade on the Toronto Stock Exchange. Check the ticker for companies like SunLife (SLF.TO $44.20/share); Manulife (MFC-PM.TO $19.65/share); Industrial Alliance (IAG.TO $44.83/share); Great West Life (GWO-PN.TO $13.26/share).
The more money which insurer pay out to you, the less money they get to report in profits for their shareholders and on the stock exchange. If insurers paid out each and every claim without issue which came their way, they wouldn’t be profitable. The goal of a publicly traded corporation is to MAKE MONEY. That’s it. There is no other goal. If they wanted to be charities, they would be set up as such.
Keeping that in mind, an insurer will do anything in their power, and look for any reason or any “out” to deny your claim at first instance. This keeps the insurer as profitable as profitable as can be.
Some of the big reasons we see claims getting denied at first instance include, but aren’t limited to:
- Not Enough Medical Information: It may not be enough to have your doctor(s) complete the medical certificate forms which the insurer provides. The insurer will likely ask for your doctor’s complete chart, hospital records, treatment records, employment records, tax returns etc. Insurers will NOT approve a claim without getting the whole picture of your pre-disability health history, and your post-disability health history.
- Claim was submitted too late: The LTD policies are written by insurers. Accordingly, in these policies there can be very strict limitation periods in terms of when and HOW to properly file a claim. Our best advice is to APPLY as early as you possibly can once your doctor says you ought not return to work. The longer you wait to apply, the more time will pass and the greater the likelihood your claim might get dismissed on account of delay or missing a limitation period. Don’t delay!
- LTD Claim forms not properly completed: The claims forms are complicated for a reason! Do you really think the insurer just wants to hand over money to you? Don’t be so naive. Completing the claims forms can be tricky, particularly for somebody whose English isn’t the best. Doctors and employers also don’t like filling out these forms. They are timely, complicated and they don’t get paid for completing the forms unless you have the money to pay them out of your own pocket. There’s no OHIP Billing Code for completing an insurance form.
- No evidence of disability: This is one of the top reasons we see for denial. What appears to be a serious and disabling condition to YOU, is viewed by the insurer and their “medical experts” as just a common ache that you can work through. Just take a Tylenol and suck it up; you’ll be ok is what they say. Some injuries are objective (broken bones). Other injuries are subjective (your back pain or depression). Either way, your ability to work, or being unable to work is rather subjective. Insurers tend to lean on the side of what they call “hurt vs. harm” and believe that if you just suck up your pain, you can work through anything. Easy for them to say; they aren’t the ones dealing with the pain, depression or anxiety. Truth is, they just don’t get it; and even if they did; it’s not in their best interest to be on your side and believe your version. That just means they have to pay you money, which is contrary to what we discussed above being a publicly traded company. Profits over people…
- A Pre-Existing Condition: Most LTD policies contain a provision such that no benefits will be paid for a pre-existing condition. Here is a Pre-Existing condition clause from an actual LTD policy we have seen used against one of our clients by a large insurer:
No benefits are payable for:
A Pre-Existing Condition which causes Disability within the first 12 months of insurance under this Benefit. A Pre-Existing Condition is any injury or illness (whether diagnosed or not) for which an Employee was treated or attended by a Physician, or for which Drugs were prescribed, within 90 days prior to the date the Employee’s insurance under this Benefit became effective.
The wording of that clause is so onerous against the disability claimant, almost anything in the first 12 months prior to the disability date, can, and will be used against that person (whether diagnosed or not!).
At the end of the day, this is likely your first time making an application for LTD benefits. This is NOT the first time the insurer has seen an application like yours. They handle LTD applications all day long. It’s their job. It’s one of their primary streams of income. We tell people that a terrible LTD policy is ALWAYS better than NO POLICY. If you have an LTD Policy, be thankful you have some protection; as opposed to no protection at all. One of the most important things is that your LTD benefits don’t just magically appear because you believe that you’re disabled. You first have to make a claim; and make a claim the right way. If you happen to get denied, don’t fret. Lawyer up and Get Goldfinger! It’s your best protection for fighting a large, deep pocketed insurance company.