An Overview of Long Term Disability Claims in Ontario-1-800-JUSTICE®

This video discusses the complexities of long-term disability claims, which can arise from insurance contracts between employees and insurers. It highlights that individuals can obtain coverage through employment or individually, with policies typically covering up to 66% of income. The video emphasizes the importance of understanding the terms of these contracts, particularly the two-year mark when the criteria for disability assessment changes. It also addresses the challenges faced by claimants with invisible impairments, such as mental health issues and chronic pain, which insurance companies often deny. Viewers are encouraged to contact Preszler Injury Lawyers for assistance with denied claims and to understand their rights under their policies. For more information, reach out to 1-800-JUSTICE.

Long-term disability claims stem from a contract of insurance that generally exists between an employee and an insurance company. However, it is important to note that you do not have to be an employee to purchase a long-term disability contract or benefits. This type of coverage can be obtained either through an employment setting or individually. Many companies that provide long-term disability coverage offer different levels of coverage.

Most policies, and I can only provide a general overview of how these policies work, typically cover up to 66% of your income. This percentage is calculated based on your gross income, although it can also be based on your net income. Each contract is different, so it is essential to speak with your broker or the insurance company to find a policy that is right for you.

Most people understand that this insurance policy will provide coverage in the event that they are no longer able to work in their own job. The first part of the test in most of these contracts is that, for the first two years, you must be totally disabled from your own job. This means you have to be totally disabled for the first 104 weeks. These policies also have an elimination period, which means they will only start paying you after your disability affects your ability to work for more than 90 or 120 days. This elimination period is referenced in your policy.

Once the benefits kick in, they will pay for the first two years, provided you are unable to do your own job. A significant amount of litigation arises at or near the two-year mark. This is when people start reaching out to my firm to discuss their options. At the two-year mark, the test changes from whether you can do your own job to whether you can do any type of job for which you are reasonably suited, based on your experience, age, and various other factors. It is at this two-year mark that most insurance companies will terminate your benefits or claim that, although you have a disability, they believe you are still able to do another job. As a result, they will terminate your benefits.

Most litigation arises around the two-year mark, which leads to two options. Your first option is to do nothing, which means you will effectively receive no further compensation from your insurance company despite having paid for these benefits. Alternatively, you can contact a law firm or a lawyer to litigate the denial. Essentially, these claims are breach of contract claims. You had a contract with an insurance company, and they have breached it by failing to honor the terms of the contract.

The insurance company's position is that you are able to do another job for which you are reasonably suited. However, generally, if you are unable to do your own job, you are likely unable to do any job. The question often becomes focused on your injury, condition, or symptoms, but the real test is impairment. Impairment is the key factor, and the test focuses on whether you can do your job or any type of job. Whatever your condition may be is secondary. While it helps inform whether your impairments reach a level that prevents you from working, it is not specifically about whether you have cancer, an autoimmune issue, or a heart condition. It is all about the effects or impairments stemming from those disabilities, conditions, or injuries.

We see a significant difference between physical claims and mental or behavioral claims. Insurance companies often deny claims involving invisible impairments. An invisible impairment is something that cannot be seen on an X-ray or any imaging. Examples of these claims include mental health issues and conditions related to pain. We do not have a machine that can quantify pain levels, so individuals with fibromyalgia or chronic pain often face challenges. Claims involving concussions, tinnitus (ringing in the ear), vertigo (dizziness), and headaches are also common. These are all considered invisible impairment claims, which insurance companies find easier to deny because they may question the credibility of the claimant.

However, we know that these are legitimate disorders that create significant impairment. The test remains: if you cannot work and are totally disabled, then you qualify for your benefits. Part of what we do as lawyers is ensure that we hold the insurance companies to the strict terms of their contracts. We add value by not only making sure you receive the benefits you are entitled to, but we also help you obtain punitive and aggravated damages, which is an additional amount of money to penalize the insurance company for their bad behavior.

In the event of a denial, you have options. You can call a lawyer and commence a lawsuit for your losses and the benefits you are entitled to under the long-term disability contract. We can also help you access or qualify for Canada Pension Plan (CPP) disability, which most insurance companies require you to apply for. Even though you may believe this is a benefit you have paid for through your employment, the insurance company actually receives credit for it. For example, if your benefit was $2,000 and your CPP disability amount was $1,000, it is not as if you receive $3,000. The insurance company will simply reduce the amount they owe you by $1,000, and you will still receive $1,000.

You may find this situation to be unfair, and it is, as you and the government of Canada are effectively subsidizing billion-dollar corporations. Unfortunately, no one has changed the legislation to disallow insurance companies from doing this. This is the current state of the law in Ontario. If you do not apply for CPP disability, the insurance company will unilaterally discount what they owe you as if you are receiving it. Therefore, it is always best to apply, and my law firm can assist with that.

Another issue that arises when people are forced to apply for CPP disability is that the government will provide you with retroactive payments that cover you back to the date of the onset of your disability. This could result in a payment of $10,000 or $20,000. However, this can create complications with your own insurance company, as they may claim you owe them that $20,000. If you have spent that money, you may face issues with your insurance company, as they will expect repayment.

If your long-term disability claim has been denied or if your long-term disability carrier is making your life difficult with respect to your policy and is asking you questions you cannot answer, feel free to give my law firm a call for a free consultation. We will help answer your questions and ensure you are fully aware of your rights under your policy. We will also articulate what we can do for you in a practical sense.