What to Do If Your Long-Term Disability Claim is Denied in the Greater Toronto Area
If you've been denied a long-term disability (LTD) claim, it can be a devastating blow. It can leave you feeling lost, frustrated, and financially insecure. However, it's important to know that you have options.
Understanding the Denial Process
Before exploring your next steps, it's crucial to understand why your claim was denied. Common reasons for denial include:
- Insufficient Medical Evidence: The insurance company may argue that your medical records don't adequately support your claim.
- Failure to Meet Occupational Requirements: The insurer may contend that you can still perform the essential duties of your job.
- Pre-existing Condition: If your disability is related to a pre-existing condition, the insurer may deny your claim.
- Failure to Follow Treatment Plans: Non-compliance with treatment plans can be grounds for denial.
What to Do After a Denial
- Review the Denial Letter: Carefully examine the denial letter to understand the specific reasons for the decision. This will help you identify potential weaknesses in the insurer's argument.
- Consult with a Disability Lawyer: A skilled disability lawyer can assess your case, identify potential legal issues, and advise you on your next steps.
- Appeal the Decision: Most insurance policies allow for an appeal process. Your lawyer can help you file a formal appeal, providing additional medical evidence and legal arguments to support your claim.
- Consider Litigation: If the appeal is unsuccessful, you may need to file a lawsuit against the insurance company. A seasoned lawyer can guide you through the litigation process and represent your interests in court.
How Benjamin Law Firm Can Help
At Benjamin Law Firm, we understand the complexities of long-term disability claims and the challenges faced by individuals who have been denied benefits. Our experienced lawyers have a proven track record of success in helping clients obtain the compensation they deserve.
Here's how we can help you:
- Thorough Case Evaluation: We will carefully review your case, identify potential legal issues, and assess the strength of your claim.
- Strategic Approach: We will develop a customized legal strategy tailored to your specific circumstances.
- Aggressive Representation: We will aggressively advocate for your rights and fight for the maximum benefits you are entitled to.
- Expert Medical and Vocational Evidence: We will work with medical and vocational experts to gather compelling evidence to support your claim.
- Negotiation and Settlement: We will negotiate with the insurance company to secure a fair settlement on your behalf.
- Litigation: If necessary, we will file a lawsuit and represent you in court.
Don't Give Up on Your Claim
A denied long-term disability claim can be a significant setback, but it's important to remember that you still have options. By working with a skilled disability lawyer, you can increase your chances of a successful outcome.
Contact Benjamin Law Firm Today
If you've been denied long-term disability benefits in the Greater Toronto Area, don't hesitate to contact Benjamin Law Firm.
We offer free consultations to discuss your case and answer your questions.
Greater Toronto Area's Trusted Personal Injury Law Firm
Facing a long-term disability (LTD) claim denial is one of the most stressful experiences a person can endure, especially here in the Greater Toronto Area (GTA). You’ve been paying premiums, you’re unable to work due to a serious medical condition, and you rely on these benefits for financial survival. Then, the letter arrives—your claim has been denied. This denial is often based on the insurance company's interpretation of medical evidence, surveillance reports, or technical policy language. It is crucial to understand that a denial is not the final word. You have legal options, and the appeal process is your next step toward securing the benefits you deserve. At Benjamin Law Firm, we understand the complex tactics insurance companies use to protect their bottom line. Benjamin Law Firm has some of Greater Toronto Area's Top Personal Injury, Car Accident, Long-Term Disability and Employment Lawyers. Over 3,500 Families Helped. Over $60 Million In Settlements Recovered For Clients. We are here to guide you through the process of challenging that denial effectively and efficiently. Understanding the Denial and Your Options The first step after receiving a denial letter is to critically analyze the reasons provided by the insurer. The denial letter should clearly state the grounds for their decision. Common Reasons for LTD Claim Denial In the GTA, denials are typically based on a few recurring issues: Insufficient Medical Evidence: The insurer claims your doctor’s notes, tests, or reports do not provide objective proof that your disability prevents you from performing your job duties (or any job duties, depending on the definition in your policy). Conflict with the Policy Definition: Many policies shift from an "Own Occupation" definition (unable to do your specific job) to an "Any Occupation" definition (unable to do any job for which you are reasonably suited by education, training, or experience) after 24 months. The insurer may deny the claim if they believe you meet the latter definition. Surveillance and Social Media: The insurer may hire investigators to observe you or scour your social media accounts. If they find evidence they claim contradicts your stated limitations, they will use it as grounds for denial. Technical Issues: This can include missing forms, claims filed past deadlines, or issues with premium payments. The Two Paths After Denial: Internal Appeal vs. Legal Action Once denied, you generally face two main choices: Internal Appeal (Reconsideration): You submit additional information to the insurer and ask them to reconsider their decision. Commencing Legal Action (Lawsuit): You bypass the internal appeal (or pursue it simultaneously) and initiate a lawsuit against the insurance company. Warning on Internal Appeals: While an internal appeal sounds like the logical next step, it often favors the insurer. It simply gives them a second chance to look at your case with no obligation to reverse their decision, potentially delaying the process and allowing the limitation period for filing a lawsuit to creep closer. Strategic Legal Action: The Smart Approach to Appeal For most denied LTD claimants in the GTA, the most effective and decisive path is to bypass the internal appeal and pursue immediate legal action. This sends a clear signal to the insurance company that you are serious and places the decision in the hands of the courts, not the insurer’s in-house reviewers. 1. Reviewing the Policy and Limitation Period The first and most critical step a lawyer takes is reviewing your specific LTD insurance policy. This policy is the contract that governs everything. Understanding the Definitions: We clarify the exact definition of "total disability" in your policy (Own Occupation vs. Any Occupation) and the corresponding benefit payout period. The Limitation Period: In Ontario, there are strict deadlines—called limitation periods—for filing a lawsuit. Missing this deadline, typically two years from the date of the denial, means you lose your right to sue forever. A lawyer ensures this critical deadline is met. 2. Gathering Strong, Objective Medical Evidence The core of any successful appeal lies in objective medical evidence that directly contradicts the insurer's denial reasons. Specialist Reports: Your initial documentation may have been insufficient. Your lawyer will coordinate with specialists (e.g., orthopedic surgeons, neurologists, psychologists) to obtain detailed reports. These reports must clearly explain: The diagnosis and prognosis. The specific functional limitations imposed by the condition (e.g., "cannot sit for more than 30 minutes," "lifting restricted to 5 lbs."). Why these limitations prevent you from performing the material duties of your job (or any suitable job). Objective Test Results: The insurer often dismisses pain-based claims. Your lawyer will ensure the file is bolstered with objective data like MRIs, CT scans, blood work, or specialized functional capacity assessments (FCAs). 3. Addressing the Insurer's Specific Denials Your legal strategy must directly confront and dismantle the arguments presented in the denial letter. Challenging Surveillance: If surveillance footage is cited, a lawyer can assess whether the footage genuinely contradicts your claim or if it is misleading and taken out of context. For example, a claimant restricted from work who is filmed walking their dog is likely still within their stated limitations. "Any Occupation" Claims: If the denial is based on the Any Occupation test, your lawyer will gather evidence proving that your disability prevents you from performing any job for which you are reasonably qualified, not just your former job. This often involves vocational experts. 4. Commencing Litigation and Negotiation Once legal action is commenced, the dynamic shifts. The insurer now faces the cost and risk of litigation. Filing the Statement of Claim: This formal document outlines the legal grounds for your case and the benefits you are seeking, including past arrears, future benefits, and often damages for bad faith (if the denial was particularly egregious). Mediation and Settlement: The vast majority of LTD lawsuits settle before trial. Your lawyer will negotiate fiercely on your behalf during mediation to secure a lump-sum settlement or reinstatement of your monthly benefits. Why Legal Representation is Essential in the GTA Trying to negotiate or sue a massive insurance corporation on your own is highly inadvisable. They have teams of adjusters, in-house medical consultants, and lawyers whose sole job is to minimize payouts. Leveling the Playing Field Insurance law is complex, and the terms and conditions of an LTD policy are often dense and open to interpretation. An experienced LTD lawyer: Knows the Case Law: We understand past court decisions that interpret similar policy clauses, giving us leverage in negotiations. Manages the Burden: We handle all communications, deadlines, and the stressful administrative work, allowing you to focus entirely on your health and recovery. Maximizes Recovery: We not only fight for the benefits you are owed but also for interest and potential damages for bad faith, often resulting in a higher financial recovery than you could achieve alone. Don't Give Up on Your Benefits A long-term disability denial is a significant setback, but it is a challenge you can overcome with the right legal strategy. In the competitive legal environment of the Greater Toronto Area, you need advocates who are experienced, aggressive, and committed to your welfare. At Benjamin Law Firm, we have a proven track record of successfully challenging insurance giants and recovering substantial settlements for our clients. We understand the physical and emotional toll a denial takes and are prepared to fight tirelessly to secure the financial stability you need. Benjamin Law Firm has some of Greater Toronto Area's Top Personal Injury, Car Accident, Long-Term Disability and Employment Lawyers. Over 3,500 Families Helped. Over $60 Million In Settlements Recovered For Clients. Don't face the insurance company alone. Book a free consultation with Benjamin Law Firm today to discuss your denied LTD claim and take the first step toward appeal.
A car accident in the Greater Toronto Area (GTA) is a stressful and overwhelming experience. You’re dealing with property damage, potential injuries, and the sudden disruption to your life. Amidst this chaos, one of the first and most critical interactions you'll have is with an insurance adjuster. For many, the insurance claims process in Ontario's "no-fault" system is confusing. While your own insurance company (regardless of who was at fault) handles your mandatory Accident Benefits (SABS) claim, the adjuster’s primary goal is to close the claim quickly and for the least amount possible. This realit y makes it crucial for you to approach every interaction with caution, diligence, and a clear understanding of your rights. This is where expert legal guidance becomes invaluable. Understanding the Adjuster's Role When you report a car accident to your insurer, an adjuster is assigned to your case. Their function is twofold: to investigate the accident and to evaluate your claim for benefits and compensation. This evaluation is not necessarily an impartial assessment aimed at maximizing your payout. Instead, the adjuster is an employee of the insurance company—a for-profit entity—meaning their loyalty lies with their employer's financial interests. Understanding this dynamic is the first step toward effectively protecting your claim. Any information you provide, or any document you sign, can potentially be used to minimize the value of your case later on. This is true whether you are dealing with your own insurer for Accident Benefits or the at-fault driver's insurer for a Tort claim (a lawsuit for pain and suffering, loss of income, and future care costs). Key Steps to Take Immediately After an Accident The minutes, hours, and days following an accident are critical. Your actions during this time lay the foundational evidence for your claim. Secure Documentation and Seek Medical Attention Prioritize Your Health: Your well-being is paramount. Seek immediate medical attention, even if your injuries seem minor. Some serious injuries, like whiplash or concussions, may not present symptoms for days or even weeks. Prompt medical records create an essential link between the accident and your injuries, which an adjuster might otherwise challenge by suggesting delayed treatment means the injury isn't serious. Document the Scene: At the accident site (if safe to do so), take copious photographs of the damage, the position of the vehicles, and any relevant road conditions or signage. Collect the names, phone numbers, and license plate information of all drivers and witnesses. Report to Your Insurer Promptly: In Ontario, you must notify your insurer of your intention to apply for Accident Benefits within seven days and submit the completed OCF-1 Application for Accident Benefits within 30 days of receiving the forms from your insurer. Failing to adhere to these deadlines can jeopardize your claim. Navigating Communications with the Adjuster Once the claim is filed, the adjuster will be in contact. How you manage these interactions is vital to securing fair compensation. Do Not Provide a Recorded Statement A common tactic used by adjusters is to request a recorded or written statement, often under the guise of "standard procedure" or "clarifying details." Be Cautious: Politely decline to provide a recorded statement without legal counsel. Remember that adjusters are highly trained to ask specific questions designed to elicit details that might undermine your claim. An innocent answer about how you are feeling or what you were doing at the moment of impact could be misinterpreted or used against you to suggest partial fault or a less severe injury. Stick to Facts: If you must speak with the adjuster, provide only the basic facts: your name, contact information, the date and location of the accident, and the basic type of accident. Refer all questions about your injuries or prognosis to your doctor or, better yet, to your personal injury lawyer. Never Sign Documents Without Legal Review Adjusters may send various forms, including medical authorizations (OCF-5) or blanket releases. Review All Documents: Never sign a document without fully understanding its purpose and implications. For example, a broad medical authorization might allow the insurer to delve into your entire medical history, searching for a pre-existing condition to argue your current injuries are not solely a result of the car accident. Settlement Offers: Adjusters sometimes offer a quick, low settlement, especially if you have not retained a lawyer. They hope you'll accept this small sum out of desperation or to avoid a lengthy process, before the full extent of your long-term injuries is known. Do not accept a first offer. Once you sign a full and final release, you give up all rights to seek further compensation, even if your condition worsens dramatically. The Power of Legal Representation Dealing with the intricacies of Accident Benefits, the “threshold” test for Tort claims (the right to sue the at-fault driver), and the complex negotiations with insurance companies is a full-time job. You should be focused on your recovery. Protect Your Rights and Maximize Your Claim A personal injury lawyer acts as your shield and advocate. Handling the Adjuster: Your lawyer takes over all communication with the insurance adjusters, preventing you from making inadvertent mistakes that could weaken your case. They understand the legal deadlines, the types of benefits available, and the best way to present evidence of your injuries and losses. Fighting Lowball Offers: A lawyer has the experience to accurately value your claim—including current and future medical needs, lost wages, and compensation for pain and suffering—and the leverage to negotiate a fair settlement. If a fair settlement cannot be reached, they are prepared to fight for your rights through mediation, arbitration (at the Licence Appeal Tribunal for Accident Benefits disputes), or the court system. Don't Go It Alone After a car accident in Toronto, the process of dealing with insurance adjusters can feel like an uneven battle. The adjuster's experience and corporate mandate often place the unrepresented victim at a severe disadvantage. Protecting your legal and financial future means being informed, cautious, and proactive. The best defense is to hire a legal team that can level t he playing field. Benjamin Law Firm has some of Greater Toronto Area's Top Personal Injury, Car Accident, Long-Term Disability and Employment Lawyers. Over 3,500 Families Helped. Over $60 Million In Settlements Recovered For Clients. If you or a loved one has been injured in a car accident, don't face the insurance giants alone. Contact Benjamin Law for a confidential, risk-free consultation to ensure you receive the full and fair compensation you deserve.
When a serious illness or injury prevents you from working, the financial uncertainty can be just as debilitating as the medical condition itself. In the Greater Toronto Area, two primary systems exist to provide income replacement for disabled individuals: Long-Term Disability (LTD) insurance and Workers' Compensation, administered by the Workplace Safety and Insurance Board (WSIB). While both are designed to help you, they are fundamentally different in their purpose, eligibility, and the claims process. At Benjamin Law Firm, we have a deep understanding of these complex systems. As some of the Greater Toronto Area's Top Personal Injury, Car Accident, Long-Term Disability and Employment Lawyers, we have helped over 3,500 families navigate their claims and have recovered over $60 Million in settlements. Our goal is to provide clear, actionable guidance to ensure you get the financial support you need. This guide will clarify the key distinctions between LTD and Workers' Compensation so you can make an informed decision about your legal rights. Understanding the Core Purpose The most significant difference between LTD and Workers' Compensation lies in the cause of the disability. Workers' Compensation (WSIB) The Workplace Safety and Insurance Board (WSIB) is a government agency that provides a "no-fault" insurance system for workers in Ontario. Its sole purpose is to provide benefits and services to workers who have suffered an injury or illness that is a direct result of their work . This is a crucial point: if your injury happened at home, during your commute, or on vacation, you are not eligible for WSIB benefits. The system is funded entirely by employer premiums and is designed to provide timely access to benefits for medical care, wage replacement, and return-to-work support without the need for a lawsuit against the employer. Long-Term Disability (LTD) Insurance LTD is a form of private insurance, often provided as part of an employee's group benefits package or purchased individually. It is designed to provide a financial safety net when a medical condition prevents you from working, regardless of how or where the condition was incurred . This means a disability from a chronic illness (like MS or Crohn's disease), a non-work-related car accident, or a fall at home would all be eligible for an LTD claim, as long as the disability meets the policy's definition. Eligibility and the Claims Process The cause of the disability dictates which system you should apply to, and the application process for each is distinct. WSIB Claims Process To be eligible for WSIB benefits, you must demonstrate that your injury or illness is work-related. The process is straightforward: Report the Injury: You must report the incident to your employer immediately. Seek Medical Attention: See a healthcare provider who can diagnose your condition and confirm that it is work-related. File a Claim: You, your employer, and your healthcare provider must all submit specific forms to the WSIB within a certain timeframe. The WSIB will then adjudicate the claim. Because it is a no-fault system, you do not need to prove negligence on the part of your employer. The focus is simply on whether the injury arose "out of and in the course of" your employment. LTD Claims Process The LTD claims process is more complex and requires you to meet the specific definition of "disability" outlined in your insurance policy. This definition typically has two stages: "Own Occupation" (Years 1-2): For the first two years of a claim, you must prove that your disability prevents you from performing the essential duties of your own specific job. "Any Occupation" (After 2 years): After two years, the definition of disability changes. You must then prove that you are unable to perform the duties of any occupation for which you are reasonably suited by education, training, or experience. The LTD application requires detailed forms and comprehensive medical evidence from your treating physicians. It is not uncommon for insurance companies to deny LTD claims, often citing a lack of objective medical evidence or a failure to meet the policy's definition of disability. Differences in Benefits and Limitations The benefits provided by each system and their limitations also vary significantly. WSIB Benefits Primary Coverage: WSIB benefits primarily cover loss of earnings and medical expenses directly related to the workplace injury or illness. Benefit Amount: They typically provide a higher percentage of your pre-injury income (up to 85% of your net average earnings). Medical Care: WSIB pays for medical treatment, prescriptions, and rehabilitation services for the work-related condition. No Lawsuits: By accepting WSIB benefits, you generally give up your right to sue your employer for the work-related injury. This is the cornerstone of the no-fault system. LTD Benefits Primary Coverage: LTD benefits are solely for income replacement, typically paying a lower percentage of your income (often 60% to 70%). Medical Care: LTD policies do not cover medical expenses. These are covered by your private or provincial health insurance (OHIP). Duration: Benefits can last for a fixed period (e.g., 2, 5, or 10 years) or until age 65, depending on the policy. Private Negotiation: You retain the right to sue the insurance company if your claim is wrongfully denied. Can You Receive Both? The "Offset" Clause This is a critical point of confusion for many. In a situation where a disability is caused by a workplace incident, you may be eligible to apply for both LTD and WSIB benefits. Most LTD policies contain an "offset" clause, which means that any money you receive from WSIB will be deducted from your LTD payments. In practice, this means your LTD insurer will likely reduce your monthly benefit payment by the exact amount you receive from the WSIB to prevent "double-dipping." In many cases, WSIB benefits are higher than LTD benefits, which could result in your LTD benefit being reduced to zero while you receive WSIB payments. However, you should still apply for both if eligible. Here’s why: WSIB Denial: If your WSIB claim is denied, you still have the LTD claim as a backup. Benefit Duration: WSIB benefits may not last as long as your LTD benefits. If WSIB benefits are cut off or reduced, your LTD benefits can "top up" to the full amount. Legal Protection: Your LTD policy may have a requirement that you apply for all other available benefits, including WSIB. Failure to do so could lead to a denial of your LTD claim. The Role of an Experienced Lawyer Navigating the intricacies of both WSIB and LTD systems can be overwhelming. The definitions are complex, the paperwork is extensive, and the stakes are high. An experienced lawyer can be invaluable in this process. WSIB Appeals: If your WSIB claim is denied, you have a right to appeal the decision. This is a complex process that requires an understanding of WSIB's policies and procedures. LTD Claim Denials: If your LTD claim is denied, a lawyer can assess the denial letter, gather the necessary evidence, and file a lawsuit against the insurer to fight for your rightful benefits. Coordinating Your Claims: A lawyer can help you coordinate your WSIB and LTD claims to ensure you are meeting all policy requirements and maximizing your benefits without jeopardizing either claim. Conclusion While both Long-Term Disability insurance and Workers' Compensation are essential safety nets for individuals unable to work due to a medical condition, they serve different purposes. WSIB is for work-related injuries and illnesses, while LTD covers a broader range of disabilities regardless of cause. Understanding these distinctions is crucial for anyone facing a period of disability in the Greater Toronto Area. If you are dealing with a disabling condition and are unsure which path to take, or if your claim has been denied, don't face the complex legal systems alone. Benjamin Law Firm has some of the Greater Toronto Area's Top Personal Injury, Car Accident, Long-Term Disability and Employment Lawyers. We have helped over 3,500 families and recovered over $60 Million in settlements. We are here to help you get the justice and compensation you deserve. Contact us today for a free consultation. Disclaimer: This blog post contains general information only and does not constitute legal advice or create a lawyer-client relationship. Long-Term Disability claims are complex and fact-specific. Laws and insurance policies vary. You should consult with a qualified Long-Term Disability lawyer licensed in your jurisdiction regarding your specific situation. Contact Benjamin Law Firm for personalized legal counsel tailored to your needs in the Greater Toronto Area.
BOOK YOUR FREE CONSULTATION
Fill out the Case Evaluator form below to discuss your case or claim with one of our experienced Family-First legal professionals. At Benjamin Law, we work hard, and fast to get you justice, to solve your problems, and get you the compensation that you deserve.