Steps to Take After Your LTD Claim is Denied

Having your long-term disability (LTD) claim denied by your insurance company can not only be a traumatic experience, it could also have serious consequences for your future. Not knowing what to do, or even knowing what your options are, can leave people feeling helpless and overlooked. We at Preszler Injury Lawyers have extensive experience in handling LTD denial claims and relish the opportunity to guide our clients through what would normally be a very difficult experience. Our clients often ask, what are the appropriate steps to take after my LTD claim is denied?

Before you are able to hire an Alberta long-term disability lawyer or initiate a claim, your long-term disability application must first be formally denied, which means that the insurance has sent you a letter denying your claim and outlining their reasons for doing so. This denial letter is the legal basis for your claim, and in Alberta, you have 2 years from the date of this denial letter to file a Statement of Claim (setting out the claims you wish to make against your insurer) with the courts.

Reviewing the Insurance Company’s Denial Letter

It is important to thoroughly review the insurance company’s denial letter, as there can be legitimate reasons to deny a claim.

A long-term disability claim is essentially a contractual dispute between you and your insurer. The basis for your claim is that the insurance company did not follow through on their contractual obligations to pay you the LTD benefits you are contractually entitled to.

Usually, for LTD claims, your injuries or medical condition needs to be such that it is medically determined that you are fully disabled, not only from your own profession, but from any profession. This is different from what is usually required to qualify for short-term disability (STD), where you only need to be disabled from your specific profession.

The LTD insurance policies will likely have provisions and definitions setting out the circumstances under which they can deny your claim. The denial letter will likely refer to these parts of your policy specifically when denying your claim. Some common examples would be for “pre-existing conditions” or if they determine that you are not “fully and totally disabled” as required under the policy.

In other cases, if you were not working at the time of your initial injury, you may need to be disabled from at least 2 of the following activities without assistance from another person: eating, getting in or out of bed, dressing, toileting or walking.

Ultimately, in reviewing your denial letter, you need to determine if the claim was improperly denied. If so, consider your options for internal appeal or further legal action.

Gathering Additional Medical Evidence to Support Your Appeal

Typically, the basis for denying an LTD claim is, in part, that a medical professional has given an opinion about your medical status that you don’t meet the requirements for LTD approval under the definitions in the policy.

The opinion of one doctor, whether at an Independent Medical Examination (IME) or not, does not have to be the crux of your claim. It is important that you seek out assessments or medical records that support your claim. Your lawyer may send you for a rebuttal IME opinion, or to another specialist, to have you undergo further assessments and create further evidence in support of your claim.

Ultimately, your claim will hinge on the medical evidence you gather in support of your disability. Sometimes, insurers will make a decision based on limited evidence. Gathering further evidence and providing it to the insurance company during the appeal process can be enough to help reverse their decision. However, given the complexity of interpreting contractual wording in your policy and trying to find evidence to support those findings, it can be a very difficult process to navigate yourself. Having someone there who can support your legal needs can be critical.

Requesting an Internal Review or Filing a Formal Appeal

Usually, your denial letter will include the relevant information and time periods in which you can file an internal review or internal appeal with your insurance company. Usually, and ideally, this appeal would be completed by a different insurance adjuster from the one who previously denied your claim. This allows them to have fresh eyes and an unbiased perspective in reviewing your LTD and the appeal on the current decision.

If you decide to go through the appeal process, rather than going straight to legal proceedings, it is important for you to meet the timeline requirements to file your appeal. The insurance company will likely ask you to provide a written summary of the information, along with further medical evidence, regarding why your LTD claim should not have been denied.

The specifics of the appeal process will vary a lot among insurance companies, but generally, our experience is that the appeal process often does not change the insurance company’s decision and could even provide the company with further evidence to deny your claim.

How Our Calgary Long-Term Disability Lawyer Can Help You Appeal Your Denial

Having a lawyer experienced in dealing with the insurance companies and their internal appeal processes can be a great asset as you navigate your appeal. They can help you determine if you were denied unfairly, and if so, they can assist in gathering and creating the necessary medical evidence to support your claim and hopefully be successful in your appeal or review process.

If your appeal is unsuccessful, your only avenue of recourse is through the courts. For LTD claims, there is a strict 2-year limitation from the date of your official denial letter. Unfortunately, the internal review and appeals processes do not always have the same timeline, and it is critically important that you file a claim before your limitation date passes.

A long-term disability lawyer is a legal professional, who has a professional duty to you as a client to ensure these legal deadlines are met. Insurance companies, on the other hand, are free to keep you roped along – hoping for an appeal or other internal review – only for the limitation date to pass, after which they could deny your claim regardless of its merit, because there would no longer be any legal recourse available through the courts. We at Preszler Injury Lawyers take pride and care in ensuring our client’s claims are protected properly. Far too many people who don’t hire a lawyer remain unaware of their legal rights and find themselves out of luck when they miss important legal deadlines.

Staying Organized and Persistent Throughout the Appeals Process

If you decide to go through the appeals process, rather than taking the legal route immediately (which could be another choice to consider), then it is important to keep yourself organized and be persistent in the insurance company’s process.

You need to read your LTD policy thoroughly and try to ensure you are taking appropriate steps to preserve and gather the necessary evidence to support your injuries meeting those policy definitions and policy criteria.

There is an old saying that “the squeaky wheel gets the grease” and this can be true in dealing with insurance companies. Obviously, you shouldn’t be rude, because the people you are communicating with at the insurance company are also often involved in the decision-making process that you want to rule in your favour, but you should be persistent and clear in your written communications with the insurance company. Insurance companies and insurance adjusters are busy. However, when you are persistent in seeking answers to your questions and fulfilling their requests, you can sometimes help tip the balance in your favour.

If your treatment is particularly egregious or harmful, you may want to consider alternative options for dealing with issues with insurance companies more broadly, one of which is getting professional legal advice!

Have You Had an LTD Claim Denied?

A long-term disability denial does not have to mean you will not be paid your due by an insurer. Please call us 24/7, toll-free at 1-888-494-7191 to book a free consultation. You will only have to pay for our services if we win.