You submitted the forms. Your doctor confirmed that you could not work. You waited through phone calls, medical appointments, and requests for more paperwork.
Then the denial letter arrived.
Seeing “your claim has not been approved” can feel like the insurance company has made the final decision about your health, your ability to work, and your financial future. It has not.
A denied long-term disability claim in Ontario may be challenged. Depending on your policy and situation, you can file an internal appeal, sue, or otherwise challenge the insurer’s decision. The trick is not to panic or be frustrated, but to act strategically.
Here is what you should do next, and how SG Injury Law can help you protect your right to disability benefits.
First, Remember That a Denial Is Not a Medical Verdict
An insurance company’s decision is not the same as your doctor declaring that you are healthy enough to work.
Insurers make decisions based on the wording of the disability policy and the information available in the claim file. A denial may mean that the insurer believes your medical evidence is incomplete, your limitations have not been sufficiently explained, or your condition does not meet its interpretation of the policy.
That does not necessarily mean your claim is weak.
Sometimes, medical records confirm a diagnosis but do not clearly explain how the symptoms prevent the claimant from performing specific job duties. In other cases, an insurer focuses on one report while giving less weight to the overall medical picture.
SG Injury Law assists individuals in analyzing what the insurer based the claim on, what the claim file lacks, and the best method to appeal the denial. Our team deals with long-term disability claims and provides free pre-trial consultations on LTD-related cases.
Why Are Long-Term Disability Claims Denied?
There is no single reason insurers reject LTD claims. The explanation should appear in your denial letter, although it may be written in technical or frustratingly vague language.
Common reasons include:
- Insufficient medical evidence
- Missing forms or application information
- Disagreement about your functional limitations
- Missed claim-submission deadlines
- Gaps in treatment
- Failure to follow a recommended treatment plan
- The insurer’s medical reviewer believes you can return to work
- Surveillance or social media activity that the insurer considers inconsistent with your claim
- A change in the policy’s definition of disability
From our experience at SG Injury Law, such claims can be dismissed due to errors in application, lack of information, failure to meet the deadline for filing claims, failure to prove a qualifying disability and lack of documentation. Nevertheless, there are cases when righting a wrong or presenting more persuasive evidence can result in a new decision.
The denial reason matters because your response must address the insurer’s actual concerns. Resubmitting the same documents without clarifying what the insurer misread or missed might result in another rejection.
Step 1: Read the Entire Denial Letter
It is tempting to read the first paragraph, see the word “denied,” and put the letter away. Do not do that.
Read every page carefully and look for:
- The exact reason for the denial
- The policy provisions quoted by the insurer
- The medical information the insurer reviewed
- Documents it claims are missing
- The deadline for submitting an internal appeal
- Instructions for requesting reconsideration
- The date on which payments stopped, if benefits were terminated
Pay attention to statements such as “there is insufficient objective evidence,” “you can perform the essential duties of your occupation,” or “you are capable of alternate employment.”
Those phrases reveal the argument you need to answer.
Keep the original letter and note the date you received it. SG Injury Law can review the wording of the denial and compare it with the policy’s actual terms. This is important because insurance correspondence may summarize the policy without explaining every definition, exclusion, or requirement that affects your case.
Step 2: Protect Every Applicable Deadline
The denial letter may provide a limited period in which to submit an internal appeal. That deadline varies by insurer and policy, so do not assume that you have a standard number of days.
There may also be a legal limitation period for starting a lawsuit. Ontario’s Limitations Act, 2002 generally prevents a proceeding from being commenced more than two years after the claim was discovered. Determining precisely when the limitation period begins in an LTD dispute can involve the wording of the denial, when payments ended, the policy terms, and the communications between the claimant and insurer.
Most importantly, do not assume that participating in an insurer’s internal appeal automatically pauses or extends the deadline for legal action. In most cases, it does not.
People sometimes spend months exchanging documents with the insurance company, believing the matter is still under review, only to discover that a separate legal deadline may be approaching. Contacting SG Injury Law promptly allows a lawyer to assess both the appeal deadline and the potential limitation period before either expires.
Step 3: Obtain the Policy and Claim File
Your LTD policy is the rulebook for the claim. It may define:
- What qualifies as a disability
- How benefits are calculated
- The waiting or elimination period
- Your treatment obligations
- Proof-of-claim requirements
- Exclusions and limitations
- Appeal procedures
- When the definition of disability changes
Many policies initially use an “own occupation” test. Under this type of test, the issue is generally whether the claimant can perform the essential duties of their existing occupation.
After a specified period, often two years, although the wording varies, the policy may change to an “any occupation” test. This normally reflects whether the claimant can carry out another job that he or she is reasonably qualified to do, depending on the education, training, and experience.
That change can be used to explain why a person who was getting benefits for months is suddenly given a termination letter.
You should also request information about the materials used to decide the claim, including medical reviews and relevant correspondence. A long-term disability lawyer can help determine whether the insurer had a complete and accurate picture when it made its decision.
Step 4: Strengthen the Medical Evidence
A diagnosis alone may not fully establish disability under an insurance policy.
As an example, the medical condition is identified when one says that he has chronic pain, depression, fibromyalgia, a neurological condition, or a serious injury. It does not necessarily define how the condition influences concentration, sitting tolerance, mobility, attendance, decision-making, stamina, memory or the opportunity of working a full workday.
Strong medical evidence connects three things:
Your condition, your symptoms, and your functional limitations.
Your doctor’s report may need to explain:
- Your diagnosis and medical history
- The symptoms you experience
- Their frequency, severity, and duration
- Treatments you have tried
- Medication effects or side effects
- Your physical or cognitive restrictions
- Why those restrictions prevent you from working reliably
- Your prognosis and future treatment plan
Continue attending regular medical check-ups and following reasonable treatment regimens. If you are unable to take a treatment because of cost, side effects, supply, or any other justifiable reason, you should talk to your healthcare provider and ensure the matter is documented.
SG Injury Law collaborates with medical and rehabilitation practitioners where necessary and assists clients to compile evidence as to why the insurer denies the claim. The firm’s experience in dealing with major Canadian insurers can also help anticipate how medical records may be challenged.
Step 5: Decide Whether to Appeal or Take Legal Action
Many denial letters invite claimants to submit an internal appeal. This process generally allows you to provide additional medical records, clarifications, specialist opinions, or other information for the insurer to reconsider.
An appeal may be useful when there is important new evidence that directly addresses the denial. However, it is still the insurance company reviewing its own decision.
Simply writing, “I disagree and cannot work,” is unlikely to be enough. A meaningful appeal should be supported by evidence; respond carefully to each reason given in the denial letter.
In some cases, starting legal action may be more appropriate than completing repeated internal appeals. The correct approach depends on the strength of the evidence, policy wording, deadlines, history of the claim, and insurer’s position.
SG Injury Law can assess whether an internal appeal offers a realistic path forward or whether a lawsuit should be considered. The firm’s long-term disability lawyers review denied and terminated claims, recommend a strategy, and can challenge the insurer in court when necessary.
Step 6: Be Careful What You Say and Post
The insurer might keep on collecting information after a refusal.
Always tell the truth and be consistent in any communication; however, do not make any casual statements, which may be misinterpreted. Saying, “I’m doing better,” might mean that today was slightly less painful than yesterday. An insurer could interpret it as evidence that you are ready to return to full-time work.
Social media can create similar problems. A photograph captures one moment, not the recovery time, symptoms, or assistance required before and after it. Nevertheless, insurers may use posts to question whether your activities match the limitations described in your claim.
Neither overstate nor understate your condition. Write about what you’re able to do, honestly, and what happens when you attempt to exceed your capabilities.
It is also prudent to consult legal counsel before signing a statement on record, signing a release, accepting a settlement, or attempting a return-to-work plan that your healthcare providers are not in favour of.
Can You File a Complaint Against the Insurer?
Ontario consumers may use an insurer’s internal complaint process. FSRA advises consumers to contact the insurance company’s complaint officer first and obtain a final position letter. Life and health insurance complaints may also be taken to the OmbudService for Life and Health Insurance.
However, a regulatory complaint is not the same as a claim for unpaid disability benefits.
FSRA explains that it may review whether a regulated company complied with applicable requirements, but it cannot settle a contractual dispute or award compensation to the claimant.
A complaint also should not be assumed to pause a legal limitation period. Before choosing a complaint process, internal appeal, or lawsuit, speak with an LTD lawyer about how each option affects your specific case.
Frequently Asked Questions
- How long do I have to appeal an LTD denial?
The internal appeal deadline depends on your policy and denial letter. Read the letter immediately and obtain legal advice before the stated deadline passes. - Can my claim succeed without a clear test result?
Possibly. Some disabling conditions do not produce one definitive test result. Detailed clinical records and evidence of functional limitations can still be important. - Should I return to work after my benefits are denied?
A denial does not mean you are medically ready to return. Discuss your capabilities with your treating professionals before attempting a return-to-work plan. - Can LTD benefits be terminated after being approved?
Yes. Insurers may reassess eligibility, particularly when the policy changes from an “own occupation” to an “any occupation” definition or when they believe your condition has improved. - Do I need a lawyer for an internal appeal?
It is not always mandatory, but legal guidance can help identify missing evidence, address the denial reasons, protect deadlines, and determine whether an appeal is the best option.
Speak With SG Injury Law About Your Denied LTD Claim
A long-term disability denial is more than just paperwork. It may have you wondering how you will afford to pay your bills, feed your family, receive further treatment and how to cope with a condition that already renders day-to-day life hard.
You do not need to take on an insurance company alone, without knowing your policy, your evidence and what you can do in court.
SG Injury Law serves individuals in long-term disability claims across Eastern Ontario, including Ottawa, Kingston, Brockville, Pembroke and Cornwall. Our lawyers have experience dealing with claims against large Canadian insurers and apply their understanding of how insurance companies operate to assist clients in appealing denied or discontinued benefits.
The team will be able to discuss your denial letter, review the policy, analyze the medical evidence, determine significant deadlines, and clarify whether an internal appeal or a lawsuit can be suitable.
Contact SG Injury Law for a free, confidential consultation. Acting early can give your legal team more time to preserve your options and build a focused response to the insurer’s denial.