COVID-19 Update: How We Are Serving and Protecting Our Clients

Published on:

Definition of Disability in your Long Term Disability Policy (LTD ONTARIO)

What does it take to be found disabled under your Long Term Disability Policy? A kind adjuster? A lenient policy? Good handwriting on the LTD application? A good LTD lawyer? Or is it just dumb luck?

Our lawyers wish we had the answer to get you approved right away. A good lawyer will certainly help, but a good lawyer can only play the hand that s/he has been dealt.

Even winning claims can take time to win as the insurer has to be satisfied that the applicant’s disability is not only legitimate, but also meets the definition of “disability” contained in the policy of insurance.

The tricky thing for adjusters is that every LTD policy is different. They all contain different definitions of disability, different time lines to consider, along with different benefit amounts.

Some examples of these changes which can make or break your LTD claim? Here you go!

Definition of Disability Under Policy A

During the initial assessment period (waiting period plus 24 months), the Member is considered disabled if due to illness or injury, she is unable to perform the significant duties pertaining to his/her specific work assignment (note that there was no definition or “work assignment” contained in the LTD policy)

The claimant will be considered disabled if illness or injury prevents him/her from being gainfully employed.

Gainful employment means:

  1. The Member is medically able to perform;
  2. for which The Member has at least the minimum qualifications;
  3. that provides income of at least 60% of The Member’s monthly earnings
  4. that exists either in the province or territory where The Member worked when the disability started or where they are currently living

The availability of work along will NOT be considered in assessing disability.

Definition of Disability Under Policy B

You are disabled when Insurer X determines:

You are limited from performing the material and substantial duties of your regular occupation due to your sickness or injury; and

You have a 20% or more loss in your indexed monthly earnings due to the same sickness or injury; and

During the elimination period, you are unable to perform any of the material and substantial duties of your regular occupation.

 After 24 months of payments, you are disabled when Insurer X determines that due to the same sickness or injury, you are unable to perform the duties of any gainful occupation for which you are reasonably fitted by education, training or experience.

Definition of Disability Under Policy C

“Total Disability” or “Totally Disabled” is defined as:

Restriction or lack of ability due to an illness or injury which prevents an Employee from performing the essential duties of:

  1. Her own occupation, during the Qualifying Period and the 24 months immediately following the Qualifying Period; and
  2. Any occupation for which the Employee is qualified, or may reasonably become qualified by training, education or experience, for which the Employee can earn at least 75% of Indexed Pre-Disability Earnings after the 24 months specified in part a) of this provision

Three different Long Term Disability Policies. Three different definitions of disability under the policy. Three different ways to become disabled. You can see that no case is ever the same given how these provisions work.Goldfinger-logo-icon-300x300

To add to the confusion, there are different time lines as to when the denied LTD claimant can pursue their claim or legal action. In addition to different time lines, there are also different appeal routes or methods to pursue the LTD claimant’s legal rights outside of the Court system. Here are a few examples:

LTD Policy A

When a Member disputes the decision of the Appeals Committee to deny or terminate LTD Benefits after an appeal, the Group that represents the member may, with the consent of the member, elect to submit the dispute to binding arbitration.

No legal action to recover LTD benefits under this Policy can be initiated as noted below:

  1. where a matter in dispute has been appealed and subsequently submitted to binding arbitration
  2. for 60 calendar days after notice of claim has been submitted; or
  3. more than 2 years after the LTD benefit has been denied

LTD Policy B

LIMITATION OF ACTIONS: An action or proceeding against the Insurer for the recovery of a claim under this Contract shall not be commenced more than one year after the date insurance money became payable or would have been payable if it had been a valid claim.

No arbitration rights

Two different LTD claims. Two different LTD policies. Two different ways and timelines in which to pursue your rights.

So what does it take to get your LTD appeal approved? The only thing our lawyers can tell you is that we guarantee that you won’t get approved if you don’t apply! We try to hammer this point home as much as we can. An LTD insurer won’t gratuitously hand over money to you in the for of LTD benefits if you first don’t apply for them! Only after you’ve applied, and been denied, can you then sue and recover compensation. Goldfinger-law_Logo_colour-300x78

The next biggest mistake which people make aside from not applying for LTD benefits, is apply for them when it’s too late to do so. Many LTD policies contain provisions on WHEN and LTD application needs to be made. How long that application is made after your last day of work is important. Failing to get in your application in a timely manner can kill your case before it ever stands a chance in Court. Our lawyers realize that gaining the courage to face your fears and the reality that you may never work again is significant. But doing NOTHING will result in NOTHING. Even worse, when you do finally gather the courage to make that claim, your claim may be denied at first instance because it wasn’t filed in a timely manner.

One of the final mistakes we point out to claimants is seeking assistance from doctors or therapists who don’t believe you, or who don’t believe your disability. Having a doctor who doesn’t like you, or who doesn’t believe that you’re disabled complete the LTD paper work on your behalf is a recipe for disaster. The information which they submit to the LTD insurer is often more devastating to your case than any hired gun medical expert the LTD insurer may retain. Be weary of which doctor or therapist you get help from. Make sure they will support your case for LTD benefits.

Contact Information