Appealing an LTD Denial: Step-by-Step Timeline and What to Expect

Appealing a long-term disability (LTD) denial involves a structured process that starts with notifying the insurer of your intent to appeal and typically concludes with either a negotiated settlement or a court decision.

The timeline for this process can vary significantly depending on whether you pursue an internal appeal or proceed directly to legal action.

A lawyer who handles LTD claims can provide crucial guidance on how to appeal a denied disability claim in Ontario, developing a strategy to challenge the insurer’s decision and build a case for the benefits you need.

If your long-term disability insurance claim has been denied and you need help understanding the appeals process, contact Preszler Injury Lawyers for a free consultation.

Our Toronto long-term disability lawyers can explain what to expect and help you pursue the financial support you may be entitled to under your policy.

Key Takeaways About Why Legal Representation Matters When Appealing an LTD Denial

• Strict deadlines govern your right to appeal. The limitation period to sue an insurance company for an LTD denial in Ontario is generally two years from the date of the denial. A lawyer can manage these critical timelines, protecting your right to pursue legal action.
• A strong appeal is built on comprehensive medical evidence. Insurers often deny claims by citing insufficient medical proof. Legal professionals collaborate with medical specialists to compile the supporting documentation for a disability appeal, including updated physician reports and functional assessments.
• The insurer’s duty of good faith is enforceable. Under the Ontario Insurance Act, insurers are required to act in good faith when handling claims. If your claim was denied without a valid reason, a lawyer can challenge the insurance company’s LTD decision and potentially pursue a bad-faith claim.
• Internal appeals are not always the most effective legal option. While insurers encourage internal reviews, these processes rarely lead to a reversal. A lawyer can help determine whether to engage in the LTD reconsideration process in Ontario or if filing a lawsuit is the more effective strategy.

What Are the First Steps in the LTD Appeal Process?

After receiving a denial letter, the actions you take can set the stage for your entire appeal. The insurer’s letter will outline its reasons for the denial, which provides a roadmap for the case that needs to be built against it.

Reviewing the Denial Letter

The denial letter is a critical document. It should specify why your claim was denied, referencing parts of your policy or medical information. Common reasons for LTD claim denial in Ontario include:

• The medical evidence provided does not support your inability to work.
• You do not meet the policy’s definition of “total disability.”
• The insurer believes you can perform another job based on a vocational assessment.
• Information from surveillance suggests your reported limitations are inaccurate.

A lawyer can analyze the denial letter to pinpoint the exact grounds for the denial, allowing them to identify weaknesses in the insurer’s position and begin formulating a counter-argument.

Deciding Between an Internal Appeal and Legal Action

The denial letter will almost always invite you to submit more information for an internal appeal. While this may seem like a logical next step, it is an insurer-controlled process that seldom results in a different outcome.

Key considerations for this decision include:

• The clock is ticking. The two-year limitation period for filing a lawsuit continues to run even while you are in the internal appeal process. Spending months on an appeal that is unlikely to succeed can put your legal rights at risk.
• The insurer holds all the cards. The same company that denied your claim is the one reviewing it. This creates an inherent conflict of interest.
• Legal action creates leverage. Filing a statement of claim often compels the insurance company to take the matter more seriously and can lead to more productive settlement negotiations.

Legal representation for an LTD appeal in Ontario is vital at this stage. A lawyer can evaluate the strengths and weaknesses of your case and advise whether an internal appeal is a worthwhile step or if it is more strategic to bypass it and initiate a lawsuit.

Building Your Case: Gathering Medical and Vocational Evidence

A successful appeal hinges on presenting strong, consistent, and comprehensive evidence that directly refutes the insurer’s reasons for denial. This goes beyond simply resubmitting old medical records.

Compiling Comprehensive Medical Evidence for Your LTD Appeal

The foundation of your appeal is medical proof. An insurance company may have denied your claim based on the opinion of a doctor they hired who reviewed your file for 30 minutes. Your legal team works to counter this with robust evidence, such as:

• Updated reports from treating specialists. These reports should detail your diagnosis, prognosis, and specific functional limitations.
• Functional Capacity Evaluations (FCE). An FCE is a comprehensive set of tests administered by an occupational therapist that provides objective data on your physical abilities.
• Neuropsychological assessments. For claims involving cognitive impairments from conditions like concussions or mental health issues, these assessments are critical.
• Statements from collateral sources. Input from family, friends, or former colleagues can provide real-world context to your limitations.

A lawyer coordinates with these medical professionals to obtain medical evidence for LTD reconsideration that speaks directly to the policy’s definition of disability.

Challenging Vocational Assessments

If the insurer claims you can perform another job, they have likely conducted a vocational assessment. This report identifies alternative occupations they believe you are suited for based on your education, training, and experience. However, these reports are often flawed.

Legal professionals challenge these findings by:

• Hiring their own vocational expert. A counter-report can demonstrate why the insurer’s suggested jobs are not realistic, given your medical restrictions.
• Highlighting missing information. Insurer-hired experts may overlook critical factors, such as the side effects of medication or the inability to concentrate for extended periods.

By dismantling the insurer’s vocational report, a lawyer can show that you are not just unable to do your old job but are truly unable to maintain any form of gainful employment.

What to Expect After Filing a Lawsuit Against Your Insurer

If the decision is made to proceed with legal action, a Statement of Claim is filed with the Ontario Superior Court of Justice. This document formally outlines your case against the insurance company.

The Discovery Process

Once a lawsuit is filed, both sides enter the discovery phase. This is where information and evidence are exchanged. You can expect to:

• Answer the written questions. Your lawyer will help you prepare responses to questions from the insurer about your medical history and work background.
• Attend an Examination for Discovery. You will be questioned under oath by the insurance company’s lawyer. Your own lawyer will be present to protect your interests.
• Undergo further medical assessments. The insurer may require you to attend another Independent Medical Examination (IME).

The discovery process allows your legal team to fully understand the insurer’s case and gather the evidence needed to challenge it effectively.

Mediation and Settlement Negotiations

The vast majority of LTD appeal lawsuits in Ontario are resolved before trial through a settlement. Mediation is a mandatory step in the litigation process in many parts of the province, including Toronto.

During mediation, a neutral third-party mediator helps both sides try to reach a resolution. Your lawyer will present the strengths of your case, including all the medical and vocational evidence gathered. This is often the first time an insurer is forced to confront any potential weaknesses in its denial.

If a settlement is reached, it typically involves a lump-sum payment that accounts for past benefits owed and a portion of future benefits to be paid. Your lawyer’s role is to negotiate the fairest settlement possible and advise you on whether an offer is reasonable.

How To Protect Your Rights During the Long-Term Disability Insurance Claim Appeals Process

Supporting your lawyer and avoiding common pitfalls during the appeals process can strengthen your case and improve your chances of success. Consider these practical steps to help maintain a strong claim:

• Organize all relevant documents. Keep a dedicated file with your medical records, insurer correspondence, and any forms you’ve completed. This ensures your lawyer has everything they need to build your case.
• Stay consistent in your communications. Make sure the information you provide to the insurer matches your medical records and aligns with the details shared with your lawyer.
• Follow your prescribed treatment plan. Demonstrating your commitment to recovery reinforces your claim that your condition prevents you from working.
• Avoid public discussions about your case. Refrain from posting on social media or discussing your claim with anyone other than your lawyer, as insurers may monitor your activity.
• Rely on professional legal advice. While AI tools and online resources can provide general information, they cannot replace the tailored guidance of an experienced lawyer who understands the complexities of your case.

If you’re worried that past actions may have unintentionally weakened your case, consult with a lawyer as soon as possible. They can help address any challenges and guide you toward an outcome that supports your needs.

LTD Appeal Timeline FAQs

How long does the LTD appeal process take in Ontario?

The LTD appeal process timeline can vary depending on the case’s complexity and the insurer’s willingness to cooperate. A lawyer can help streamline the process and push for a timely resolution.

What is the success rate for LTD appeals in Ontario?

Although there are no official statistics, success largely depends on the strength of the medical evidence and the quality of legal representation. Early legal intervention may help better position your appeal for the most favourable outcome under your specific circumstances.

Can my claim be denied again after a successful appeal?

If your benefits are reinstated, the insurer retains the right to periodically review your claim. However, having successfully challenged a denial once, the insurer may be more cautious about terminating benefits again without very strong grounds. A lawyer can advise you on how to protect your benefits long-term.

Do I have to pay back other benefits if my LTD appeal is successful?

It depends. If you received payments from sources like the Canada Pension Plan (CPP) Disability program, your LTD settlement might be reduced by the amounts you received. A lawyer can review all applicable policies and advise on any offset calculations to protect your financial interests.

What happens if I miss the deadline to appeal my LTD denial?

In Ontario, the limitation period to file a lawsuit is typically two years from the date of the denial. If this deadline passes, you may lose your right to take legal action. A lawyer can review your case to determine if any exceptions apply and help you act quickly to protect your claim.

Contact Preszler Injury Lawyers for Your LTD Denial Appeal

Receiving an LTD denial letter can feel like the end of the road, but it is often just the beginning of the fight for the benefits you are owed. Challenging a large insurance company requires a detailed understanding of policy language, medical evidence, and legal procedure.

You do not have to face this process alone. Preszler Injury Lawyers can guide you through every step, from analyzing the denial letter to negotiating a final settlement. We focus on building a strong, evidence-based case designed to counter the insurer’s arguments and demonstrate your continued eligibility for benefits.

Are you ready to challenge your LTD denial? Contact Preszler Injury Lawyers today for a free consultation to discuss your case and learn how we can help you move forward.

We’re here to help.