Toronto Injury Lawyer Blog
Are you familiar with the expression “don’t count your chickens before they hatch“?
It means that you shouldn’t depend or rely on something happening, until that thing or event actually happens.
As a personal injury lawyer, I tend to see a lot of this when it comes to long term disability claims.
People think that just because they have long term disability benefits, that they will automatically be entitled to those benefits. Money will rain down from the sky, and will magically appear in your bank account without having done any work for it; or without thinking about how to get approved for those benefits. They are counting the money before they’ve even been approved. They take the approval part from the insurer (which happens to be the biggest step), as a given.
Receiving long term disability benefits isn’t a given, or some sort of mandatory right that is bestowed upon a policy holder. There are a lot of hurdles which need to be cleared before an insurer will even consider an application. And once all of the paper work has been completed, and all of the forms have been submitted, it still does not guarantee that an application for long term disability benefits will be approved.
Getting the forms completed by the claimant is onerous. It’s rendered even more difficult considering this is an application for long term disability benefits and the person completing the forms is alleging that they’re disabled. That means that they are either physically or mentally not operating at 100%. Completing forms on your own is one thing. But having to rely on third parties to complete those forms is entirely different. It’s outside of the claimants control in terms of when they will get completed, and whether or not the forms will be completed the right way, or in such a way which will support the claimant’s entitlement to long term disability benefits. In addition, there might be a cost associated with the completion of the forms which the claimant is responsible to cover. None of these adds up to making the application process an easy ride for the claimant. Imagine having to pay a doctor a few hundred dollars to complete an insurance form when you aren’t able to work, earn an income, and already drowning in debt. All of that just just to apply for long term disability benefits without any guarantee that those benefits will get approved!
In addition to getting forms completed by doctors and your employer to confirm your income, work history, and hours worked, the claimant will need to gather, at their own expense, clinical notes and records from doctors, specialists, pharmacy, hospitals, and their income tax returns in order to show evidence of their health, disability, income, and frequency of treatment. Gathering these records not only takes time, but it costs money which the claimant will need to pay for out of pocket without reimbursement. This is just the cost of applying for long term disability benefits. It isn’t free. If people knew this sort of thing before they signed up, they would have a small slush fund just to pay for the cost of the records in order to apply. That slush fund should not only account for the cost of gathering records and having doctors complete forms; but also some money to make ends meet and pay the bills for a period of time while the person isn’t working.
The other consideration is that once all of the forms are completed, don’t expect the insurance company to be swift with a response one way or the other. It will take time. And even once they respond, if might not be a definite approval, or a definite denial. Sometimes, it’s a “we need more information in order to properly assess the claim“. That means that they will ask you to gather more records, again, at your own expense; or complete additional forms. All of this will take time, and cost money, all while you aren’t earning an income.
So, what does a definition of disability look like under a long term disability policy? Here are a few examples:
‘Restriction or lack of ability due to an illness or injury which prevents an Employee from performing the Essential Duties of any occupation for which he is qualified, or may reasonably become qualified, by training, education or experience. The availability of work will not be considered by the Long Term Disability Insurer in assessing the Employee’s Disability. An Employee who must hold a government permit or licence to perform his duties will not be considered Totally Disabled solely because such permit or licence has been withdrawn or not renewed.
In order to qualify for support under the Disability (STD) program there has to be evidence to confirm that the employee is totally, functionally disabled (physically and/or cognitively) from their respective job demands. In adjudicating claims to provide recommendations for your employer, several criteria are evaluated. These include a medically recognized diagnosis, symptoms consistent with the diagnosis/es that are being experienced at a level they are disabling an employee functionally, medical treatment that is evidence based and appropriate for the condition, participation in the treatment being recommended to improve the condition, and limitations and restrictions imposed by the condition such that cessation of work or continued work absence is reasonable. In order for an absence to be supported under the Short Term Disability Program, medical information is required to support that an employee is physically or cognitively disabled from performing the essential duties of their job. Additionally, you are required to be participating in appropriate evidence-based treatment. It is important to note that our decisions are made with respect to the standards in place within the program based on a medical and functional program.
In order to qualify for support under the Disability (STD) program there has to be evidence to confirm that the employee is totally, functionally disabled (physically and/or cognitively) and that continuous changes in either the diagnosis or the prescribed treatment plan are taking place due to the condition itself not being properly treated or medically managed.
