You worked, paid into a benefits plan, sought medical treatment, and submitted a long-term disability claim when your health made working impossible. Then the denial letter arrived.
It can indicate a lack of medical evidence, that you are not disabled as per the policy definition, or that the insurer believes you are still able to work. However it is worded, the message can be excruciatingly blunt: no benefits.
But a refusal does not always mean a permanent termination of your claim. The insurer chooses to pay or not depending on the policy language, the documents on file and how your condition is interpreted. Such conclusions can be disputed.
When you have had a long-term disability insurance claim denied in Ottawa or the rest of Ontario, the first thing is to know why it happened so that you can decide what to do next.
What Does “Disabled” Mean Under an LTD Policy?
In everyday conversation, disability means that a health condition has seriously limited your ability to function. An insurance company asks a narrower question: do you meet the exact definition of disability written in your policy?
Many policies initially use an “own occupation” test. You may qualify if your condition prevents you from performing the essential duties of your regular job.
Later, the policy may switch to an “any occupation” test. The insurer may then consider whether you can perform another occupation suited to your education, training, or experience. The timing and wording vary between policies.
That is why a diagnosis alone may not be enough to secure benefits. The insurer will also examine:
- Your symptoms and functional limitations
- Your medical treatment and response to it
- The duties and demands of your occupation
- Your medical records and specialist reports
- Your ability to work safely and consistently
An individual can be seriously ill, but unless documentation clearly demonstrates how the illness substantially impairs your ability to engage in your employment, the insurer can decline the claim.
Common Reasons Long-Term Disability Claims Are Denied
The Medical Evidence Does Not Explain Your Limitations
Your doctor may genuinely believe that you cannot work. However, a short note saying “the patient remains unable to work” may not answer all of the insurer’s questions.
Insurance companies often want records explaining your diagnosis, symptoms, treatment, medication side effects, test results and functional restrictions. Most importantly, the evidence should connect those restrictions to your work.
For example, how does your condition affect your:
- Concentration or memory?
- Ability to sit, stand or walk?
- Attendance and reliability?
- Decision-making?
- Ability to meet deadlines?
- Communication with clients or colleagues?
- Capacity to handle workplace stress?
A strong LTD claim explains not only what condition you have but what you can no longer do reliably because of it.
This is especially important in claims involving chronic pain, fatigue, migraines and psychological conditions. These conditions may not be fully captured by a single scan, blood test, or medical appointment.
An Ottawa long-term disability lawyer can review the insurer’s reasons and identify whether updated medical reports, specialist opinions or other evidence could strengthen your claim.
The Insurer Believes You Can Still Work
An insurer may accept that you have symptoms but decide that they are not severe enough to prevent employment.
Sometimes this conclusion is based on an incomplete job description. A position might be labelled “sedentary,” for example, but still require prolonged concentration, constant client interaction, strict deadlines, high accuracy or unpredictable working hours.
Your disability should be assessed against the work you actually performed, not simply your job title.
A detailed explanation of your essential duties may demonstrate why your restrictions prevent you from returning. Evidence of failed accommodations, reduced hours, modified duties or an unsuccessful return-to-work attempt can also be important.
If the policy has moved to an “any occupation” definition, the insurer may argue that you can perform a different job.
That raises several questions:
- Is the proposed occupation realistic given your restrictions?
- Does it match your education, training and experience?
- Does it provide a reasonably comparable income?
- Can you perform it consistently rather than only occasionally?
SG Injury Law explains that LTD benefits may be terminated when a policy moves from an “own occupation” to an “any occupation” test. We assist people whose claims were denied initially as well as people whose approved benefits were later stopped.
Your Forms or Records Contain Inconsistencies
LTD applications normally include forms completed by you, your employer and your healthcare provider. Different dates, vague answers or conflicting descriptions can create problems.
Your application may say your symptoms became disabling in March, while an earlier medical note mentions similar symptoms in January. Your employer can explain your job as administrative, and you can state that it requires much travelling and meetings which are very demanding.
The fact that someone was inconsistent does not necessarily imply that he or she was lying. The recall of information can be influenced by memory problems, medication, exhaustion, anxiety, and confusing forms.
However, insurers can exploit differences to doubt the validity of a claim. Any discrepancy must be clarified honestly and justified with context as much as possible.
The Insurer Says You Did Not Follow Treatment
Many disability policies expect claimants to participate in reasonable medical treatment.
Missed appointments, unfilled prescriptions or a refusal to attend recommended therapy may lead the insurer to argue that you are not doing enough to improve your condition.
There may be a valid explanation. A drug could have brought about severe side effects. Therapy might not have been available or affordable. A waiting list could have led to a delay in a specialist appointment. Your doctor may have advised against a particular treatment.
Do not leave the insurer to guess. Request your medical professionals to record the reason behind any change, postponement, discontinuation or medical inadvisability of treatment.
You are also to keep attending relevant appointments as your claim is under review. Lapses in records of treatment may complicate the process of proving that your condition is still severe and persistent.
Surveillance or Social Media Was Misinterpreted
A photograph of you attending a family gathering does not show how long you stayed, what assistance you needed or how you felt afterward.
Similarly, a short video of you carrying groceries does not establish that you can complete a full workday, five days a week.
Nevertheless, insurance companies may compare surveillance footage or public social media activity with the statements in your application.
Problems can arise when a claim contains absolute descriptions such as “I never leave home,” while the insurer finds evidence of an exception.
Always explain your limitations in detail. Explain the difference between good days and bad days, the assistance you need and how long it takes you to recover after an activity.
Disability is often about consistency. The question is not simply whether you can complete one task on one occasion. It is whether you can work safely, predictably and repeatedly.
The Insurer Relied on a Policy Exclusion
There are pre-existing condition clauses or exclusions in some LTD policies that relate to specific situations.
The insurer can look at previous doctor visits, symptoms, prescriptions or tests and claim that your present disability is covered under an exclusion.
The correctness of that interpretation depends on the specific phrasing of the policy and the medical timeline.
A denial letter stating an exclusion does not always put an end to the matter. This provision should be read in conjunction with the entire policy, your health records and the facts that led to your disability.
What Should You Do After Receiving a Denial?
Start by reading the entire denial letter, including the sections that appear to contain standard wording.
Identify:
- The exact reason for the denial
- The policy provisions being relied on
- The deadline for submitting an internal appeal
- The medical or vocational documents reviewed
- Any information the insurer says is missing
Next, gather your policy, application, denial letter, correspondence, job description and medical records. Keep copies of emails and make notes of telephone conversations with the insurance company.
Continue attending appropriate treatment and following the recommendations of your healthcare providers. Your ongoing records can become important evidence.
Most importantly, do not assume that submitting an internal appeal protects every legal deadline.
Ontario’s Limitations Act, 2002 establishes a basic two-year limitation period for many civil claims, generally connected to when a claim is discovered. However, determining the correct deadline in an LTD dispute can be complicated and fact-specific.
Early access to legal counsel allows your lawyer time to assess the denial, protect your rights, and avoid missing crucial deadlines.
Should You Appeal or Start a Lawsuit?
There is no single correct answer for every denied LTD claim.
An internal appeal may be useful when a clear gap can be corrected. Maybe the insurer did not get a specialist report, misinterpreted your occupation or did not look at a significant medical record.
In other cases, repeatedly submitting similar information to the same insurance company may consume valuable time without changing the result.
A lawsuit can present a better means to seek unpaid benefits or negotiate a settlement. Before advising on a course of action, an Ottawa long-term disability lawyer can review the policy, medical facts, the actions of the insurer and time limits.
A regulatory complaint is different from a claim seeking disability benefits.
The Financial Services Regulatory Authority of Ontario advises consumers to first complete the insurance company’s complaint process and obtain a final position letter. FSRA can review possible regulatory non-compliance, but it cannot settle a contractual disagreement or obtain compensation for a claimant.
This is another reason to obtain advice about all available options rather than relying on one appeal or complaint process.
Frequently Asked Questions
- Can my LTD claim be denied even if my doctor says I cannot work?
Yes. Your doctor’s opinion is important, but the insurer may argue that the report does not fully explain your functional restrictions or connect them to your job duties. A more detailed medical report or additional evidence may be required. - Does a denied LTD claim mean I have no case?
No. A denial represents the insurer’s current decision based on the information it reviewed. Depending on the circumstances, you may be able to challenge that decision through an internal appeal, legal action or another appropriate process. - How long do I have to challenge an LTD denial in Ontario?
Your denial letter may contain a deadline for an internal appeal. A separate legal limitation period may apply if you decide to begin a lawsuit. Because these deadlines are not necessarily the same, speak with a lawyer as soon as possible. - Can my benefits be stopped after the claim was approved?
Yes. An insurer may terminate benefits if it believes your condition has improved, you have not followed treatment, surveillance contradicts your reported limitations, or the policy’s definition of disability has changed. The termination decision may also be appealed. - What can a long-term disability lawyer do for me?
A lawyer can review your policy and denial letter, obtain the insurer’s claim file, identify missing evidence and communicate directly with the insurance company. Your lawyer can also advise whether an internal appeal or lawsuit is more appropriate and pursue reinstated benefits or a negotiated settlement where available.
A Denial Letter Does Not Get the Final Word
When your income suddenly stops, it is easy to feel pressured into accepting the insurance company’s explanation.
However, the words “claim denied” do not tell you whether the policy was interpreted correctly, whether your medical evidence was assessed fairly or whether important information was overlooked.
SG Injury Law focuses on personal injury, long-term disability insurance and employment claims. We represent clients throughout Eastern Ontario. Our team also has prior experience representing insurance companies, which gives us insight into how they investigate, assess, and defend claims.
In case of a long-term disability insurance claim denial, SG Injury Law may review the decision, discuss the options with you in simple terms and handle the communication with the insurer, leaving you to focus on your health.
Contact us to speak with an experienced Ottawa long-term disability lawyer during a free, confidential consultation. For every LTD matter we take up, clients do not pay a legal fee unless the case is successfully resolved.
A denial may interrupt your benefits, but it does not automatically eliminate your rights. The sooner you understand why the claim was denied, the sooner you can begin building an informed response.