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Things to watch out for when it comes to your Long Term Disability Claim (LTD Ontario)

Our law firm gets a ton of calls from people who have been denied Long Term Disability (LTD) benefits from their insurers (Great West Life, Manulife, Sun Life, Industrial Alliance, SSQ, Co-Operators, RBC Insurance, Desjardins, Equitable Life, La Captiale Insurance, Canada Life, and the list goes on…).

Although none of the people who contact our law firm have met, there are many common threads in the phone calls. A serious injury, illness or disability denied, or not properly communicated to the insurance company. Feelings of loss, anger, hopelessness, worry and despair on account of the denial. A sense of loss and simply now knowing what to do, or what to expect for their case or future.

These are all common and perfectly normal feelings. After all, you’re not a lawyer and this is probably the first time your applying for Long Term Disability benefits; let along your first time seeing how an insurer is reacting to your claim. It may be your first time calling a lawyer as well!

The experience of calling a lawyer should NOT be scary and NOT be intimidated. At our law firm, we do our very best to make the experience as comfortable and easy to understand as possible. There is no reason why excellent customer service should not extend to personal injury lawyers.

Here are some of the most common trip ups people can make before retaining a lawyer when fighting a Long Term Disability Claim:

Missing the two year limitation period!!!!!

You have two years from the date of denial to sue the insurance company. It’s the law, plain and simple. If you don’t sue within two years from the date of denial, there is a very good chance that your case will get dismissed for failing to commence your claim within time. The cases of insurers become even stronger now that most of the big LTD insurers are adding wording like this to end their letters:

Please be advised that your claim is subject to a limitation period set out in the Insurance Act of the province (excluding Ontario) or territory on which you resided at the time that you initially became insured under this policy. If you became insured in Ontario, the limitation period is set out in the Limitation Act or your employee booklet where your booklet includes a limitation period provision

We are seeing more and more insures use these blanket disclaimers regarding limitation periods in the correspondence to their insureds. That way, should the matter proceed before a Judge to determine if a limitation period has been missed, the lawyer for the insurer can point to all of these letters sent out to the insured with that warning about a limitation period lapsing in order to support their position.

Getting caught by the pre-existing condition under the terms of the LTD Policy!!!

LTD policies are carefully written by insurers to provide a product that appears great on the surface; but upon closer glance, you aren’t always getting what you think you are. There are many exclusionary clauses contained in LTD which limit the potential exposure for insurers when it comes to paying out on a long term disability claim.

Case in point: The Pre-Existing Condition clause.London Head Shot Brian Goldfinger

But what is this clause you speak of Mr. Lawyer? I’ve never heard of such a thing….

That’s right. You probably have never heard of a Pre-Existing Clause before, because you’ve never come across one before in your entire lifetime. But insurers certainly know what it is, and how it can be used to nullify a Long Term Disability Claim.

Most, if not all Group LTD Policies contain the following provision, or something just like it:

LTD Benefits will NOT be paid for a disability/injury/illness that results either directly, or indirectly from a condition, diagnosis, test, finding, or treatment that existed on or before the commencement of the employee’s insurance unless:

a) the employee became totally disabled more than 12 months after the employee’s coverage began

b) the employee was not treated or attended by a doctor/physician or prescribed drugs within 90 days prior to the effective date of coverage.

What this means is that if you’ve been working for under 12 months, and you were getting medical treatment for that disability/injury within at 12 month time period, you will not be covered. If you got treatment within 90 days prior to getting LTD coverage, the ailment which you were getting treatment for will NOT be covered.

Take this example. Sally works for a big company. She just started working there. Sally has fibromyalgia, anxiety and depression; all of which are controlled with medication. In month 11 of her work, Sally’s fibromyalgia, anxiety and depression spirals out of control such that she is no longer able to work any more. Sally applies for LTD benefits based on her fibromyalgia, anxiety and depression.

The insurer is quick to point out that Sally has had LTD coverage for under 12 months, therefore, she falls in to that “pre-ex” period. The insurer asks to see her medical records and they see that Sally been treated for her fibromyalgia, anxiety and depression during that “pre-ex” period and long before. Accordingly, the insurer can rely on the “pre-existing” exclusion to deny Sally’s claim. Had Sally stayed at work just a bit longer (beyond the 12 month pre-ex window), the insurer would not be able to rely on this exclusion. Had Sally gutted it out for another month or so, to take her work period beyond that 12 month window, it would have dramatically changed her LTD claim and likely increased the odds of getting her LTD claim approved.

Not getting your forms submitted properly!!!

Every insurer has their own set of unique forms to apply for LTD benefits. Some forms are available online. Others are available from your union rep, HR department, or management. Either way, getting these forms prepared the right way, the first time; and then submitted to the LTD insurer in a timely manner is important. Keep copies of the forms you submit. If you submit by fax, keep the fax confirmation sheet. If you send by mail, make it registered mail so that you have proof that the forms were in fact sent in. You can also call the insurer to confirm receipt of your LTD package. Getting your claim denied because your LTD application forms get lost is no way to lose out the benefits you deserve.


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