Certain medical conditions may not be accompanied by observable physical symptoms. Instead, the severity of the condition will be a subjective experience, entirely unique to the person afflicted by it and impossible to gauge using objective medical evidence. Although these conditions cannot be easily observed or objectively quantified, they could substantially impact a person’s ability to perform routine activities and may even prevent them from working.
When so-called “invisible” injuries, illnesses, or other unobservable medical conditions prevent someone from performing the duties of their job, provided they have the proper insurance coverage, this person may be able to recover long-term disability (LTD) benefits. LTD benefits are designed to supplement an insurance policyholder’s income when their medical condition makes it impossible for them to work for a substantial period of time. Typically in Canada, LTD plans usually replace between 60-70% of a recipient’s regular wages.
Although each insurance policy has different eligibility requirements for LTD benefits, generally speaking, in order to qualify for them, policyholders must be able to prove that they are currently receiving ongoing medical treatment and have been receiving treatment for a significant period of time. They must also be able to illustrate how their condition prevents them from performing the duties of their occupation. Additionally, to qualify, they generally must have already used up all other options for compensation available to them. These compensatory options may include paid sick leave, vacation time, Employment Insurance (EI) benefits, and short-term disability benefits.
After eligible policyholders submit an application for LTD benefits, it is up to their insurance provider to decide whether or not the claimant’s medical condition entitles them to collect benefits. The insurance company will use the supporting medical evidence provided by the applicant in order to make their determination.
Many claims for LTD benefits are denied, even when the applicant provides their insurer with quantifiable proof of their medical condition’s affect on their ability to work. It is even more difficult to successfully convince insurance providers to provide policyholders with the compensation they’re entitled to when the symptoms of their condition are “invisible.”
Invisible medical conditions may manifest themselves through unmeasurable pains, experienced both physically and mentally. Some examples of invisible medical conditions may include:
- Soft tissue injuries
- Chronic pain
- Traumatic brain injuries (TBI)
- Post-Traumatic Stress Disorder (PTSD)
- And more
Since the experience of internal pain and/or mental anguish is subjective, a policyholder’s claim that their condition prevents them from working can easily be dismissed by their insurance provider as false or embellished.
If you suffer from a medical condition that prevents you from performing your job, but your insurance provider unfairly denied your claim for LTD benefits, an Ontario long-term disability lawyer may be able to help recover the compensation you’re rightfully owed.
How to File a Long-Term Disability Claim for Invisible Injuries
Many people qualify for LTD coverage through their employer’s group insurance plan, or through a privately held insurance policy that they pay into individually. If you have the appropriate level of insurance coverage and have sustained an injury or developed a chronic physical or mental illness that prevents you from returning to work, you may be eligible to submit an application for LTD benefits.
If the symptoms of your medical condition cannot be quantified through traditional evidence, such as diagnostic examinations or medical imaging, it is important to compile as thorough an application as possible to substantiate your claim.
Your application for LTD benefits may be subject to certain deadlines or time limits. If you have questions about the limitations your application may be subject to, or whether or not your condition qualifies you to collect benefits, consulting with a lawyer before completing your application may provide you with beneficial advice.
After consulting with a lawyer, in order to apply for LTD benefits, you must:
- Obtain a claim form from your employer or private insurance provider.
- Compile all medical records and supporting documents from your health care providers.
- Obtain a medical certificate from your health care provider in support of your application.
- Complete all required application forms (additional information from your health care providers and employer may be required).
- Submit the completed application to your insurance provider.
Your application for LTD benefits should also include evidence proving that you have a disabling medical condition, and that you have been receiving ongoing treatment for it. This may be difficult to do if the symptoms of your condition are not easily observed through traditional medical examinations. Nevertheless, it is important to compile as much medical proof of your condition as possible, including:
- Medical records
- Results of medical examinations
- Statements from your attending physicians
- A detailed description of your job duties
- A statement from your plan sponsor (i.e. your employer)
- Other documentation proving that your medical condition prevents you from performing the duties of your job
What Percentage of LTD Claims Are Denied?
Even after presenting a thorough portfolio of evidence, including testimonies from medical experts, insurance companies often deny claims for LTD benefits to people suffering invisible injuries or illnesses.
Insurance companies are not required to share statistical information about how many LTD claims they deny each year, but by looking at information regarding the Canada Pension Plan (CPP) disability benefits, it can be assumed that most Canadian insurance claims for LTD in Canada are not approved. This determination is based on both anecdotal evidence and the fact that approximately 60% of claims for CPP disability benefits are denied.
Oftentimes, it can be difficult to understand why an insurance company would deny an application for benefits, especially if the claimant was able to supply ample evidence supporting their claim.
If your claim for LTD benefits was denied even though your condition should entitle you to compensation, an Ontario lawyer may be able to review your policy and advise you of legal options that may be available.
How a Lawyer May Be Able to Help Appeal a Denied Long-Term Disability Claim
When patients suffering from invisible injuries or illnesses submit claims for LTD benefits, their insurance providers often cite insufficient medical proof as the primary reason for denying their applications. In these situations, a lawyer may help their client compile additional evidence proving their condition’s severity and its impact on their ability to work. Doing so may help overturn the insurance provider’s initial decision. There is a limited window of opportunity in which denied benefits applicants are eligible to file an internal appeal, and so getting in touch with a lawyer immediately could be crucial.
That said, once the internal appeals process begins, it can take a long time for the insurance company to review the newly submitted medical evidence. More often than not, people who are unable to earn a paycheck because they are suffering from chronic medical conditions likely do not have the luxury of time. Plus, even after filing an internal appeal and providing additional medical evidence, the insurance company may still decide to deny an applicant’s claim for LTD benefits.
For that reason, a long-term disability lawyer may advise you to file a lawsuit against your insurance provider for unfairly denying your benefits claim. If the lawsuit is resolved in your favour, you may be awarded payments for:
- Previously denied benefits payments
- Legal fees
- Damages for mental stress experienced
- Punitive damages
- And possibly more
Call Preszler Injury Lawyers Today
If a medical condition prevents you from earning a living, even though the symptoms of that condition may not be observable to other people, you may still qualify for LTD benefits. If your claim for LTD benefits has been unfairly denied, a long-term disability lawyer may be able to appeal or litigate the insurance company’s decision on your behalf.
To discuss the details of your claim in a free, initial consultation, contact Preszler Injury Lawyers today or call us at 1-800-JUSTICE.