Having your disability claim denied is a shock. Whether you have disability insurance through your employer or bought a policy on your own, you assumed you would be able to rely on it. If you have an illness or injury that is preventing you from working, and have been denied coverage, here is what you can do.
Short-term disability vs. long-term disability
First, let’s talk about the difference between short-term disability and long-term disability. In Ontario, short-term disability (“STD”) typically provides you with benefits for up to six months immediately following a serious illness or injury (the length of STD varies by policy).
Long-term disability (“LTD”) benefits, on the other hand, are intended to replace 60 to 70 percent of your normal income (the policy will outline the percentage) if your injury or illness prevents you from working past the end of your short-term disability benefit period.
What to do if your short-term disability claim is denied
Insurance companies use all kinds of reasons to deny legitimate short-term disability claims. Mistakes in your application and missing filing deadlines are two major reasons. Another common reason is that your doctor doesn’t support your claim to go on sick leave.
STD benefit claims are often rejected due to insufficient medical evidence to support the claim. That doesn’t mean you aren’t disabled; it just means you need better medical documentation to support that your disability is serious.
If your short-term disability claim is denied, there are several steps you can take. If you are well enough you can return to work. If you are not well enough, that is obviously not an option. The first step you should take is to get the insurance company’s denial decision in writing, so you know the specific reason your claim was denied. This will guide you in appealing the denial. The next step is to find out the deadline to submit an appeal to the insurer (i.e., asking the insurance company to reconsider its decision). Internal appeal deadlines vary from policy to policy, but it is usually about 90 days.
The next step is to correct any mistakes in your application and gather medical documentation to submit with your appeal (more detailed medical records from your doctor or a specialist, a new treatment plan, etc.). If you need help determining what information to submit with your appeal, reach out for advice from an experienced long-term disability lawyer. The insurer will usually take about a month to consider your appeal. The insurance provider will either approve your claim for STD benefits or affirm its denial (which you may be able to appeal internally again).
If the denial is upheld, you may also have the option to file a statement of claim. The time to file a claim is typically directed by the policy, but it's important to note that most policies in Ontario have a one-year limitation period. It's crucial to act quickly and seek legal advice to ensure you don't miss this deadline.
If your STD claim or appeal is denied, another option is to apply for Employment Insurance sickness benefits. At the time of writing, EI sickness benefits cover 55% of your earnings up to a maximum of $650 a week, for a period of up to 15 weeks.
Lastly, even if your STD claim was denied, you can move forward with a claim for LTD benefits if your illness or injury continues to prevent you from working. It is almost a given that your insurance provider will deny your LTD disability claim if it already denied your STD claim, but you must still go through the application process. Apply for LTD benefits; if your LTD claim is denied, you then have options.
What to do if your long-term disability claim is denied
The same reasons for STD benefit denials apply to LTD benefit denials, including insufficient medical documentation, missing filing deadlines, and errors in your application. LTD claims are also commonly denied because the insurer says you aren’t “totally disabled” or because the insurance company’s doctor doesn’t think you are disabled.
If your LTD claim is denied, you can fight back. Get the denial decision in writing from your insurer. Have the letter reviewed by an experienced disability lawyer (Lindsay and Oshawa lawyers at Kelly Greenway Bruce are here to help you). Your disability lawyer can pinpoint the reason for the denial, and file an internal appeal of the insurance company’s decision, and help gather evidence to submit in support of your claim. The limitation period for filing a claim will be directed by the policy, but most policies in Ontario have a one-year limitation period from the date of denial.
You can also file a lawsuit against the insurance company for wrongfully denying your LTD claim. You have two years from the date your LTD claim was denied to file a lawsuit. You can skip the internal appeal process and go straight to filing a lawsuit, or you can try the internal appeal route and then go to court if it is not successful. However, if you use the insurance company’s internal appeal route, be very careful: insurers often use the internal appeal process to “run out the clock” on the two-year limitation period to bring a lawsuit. Once the two years have passed, the insurer doesn’t have to pay your LTD claim, and you lose the right to sue the insurance company for disability benefits.
Benefit claim denied? Get advice from a disability lawyer
Lindsay and Oshawa lawyers at Kelly Greenway Bruce know all the tricks and tactics insurance companies use. Once you hire Kelly Greenway Bruce, we deal with the insurance company on your behalf. No more struggling to figure out deadlines or dealing with insurance company gaslighting. You can focus on recovery, knowing that you have a trustworthy advocate on your side. We encourage you to connect with our disability lawyers in Lindsay or Oshawa today.