If you have been disabled and are unable to work, you may be entitled to short-term (STD) and/or long-term (LTD) disability benefits. The following questions and answers provide useful information pertinent to disability claims generally and disability insurance disputes specifically.
This general information is not legal advice. If you have specific questions about your case, please contact Geoff Aylward, insurance dispute lawyer in Newfoundland and Labrador.
1. How much disability insurance coverage should I have?
Disability insurance is often used as a safety net as a source of funds for a person or family should an accident or illness occur and prevent a person from working for any amount of time. When you are calculating the amount of disability coverage you should obtain, there are multiple factors that should be considered if you want coverage that will provide similar quality of life you experienced before an injury or illness made you unable to work. Factors to consider include:
- Risk Assessment. What type of job do you have? What are the dangers or risks? What type of lifestyle do you live? Is there high or low potential for risk of injury or illness?
- Financial Resources. Do you have any savings or investments that you can fall back on if needed? How long could you last off of your savings?
- Family Responsibilities. Does anyone depend on you and your income? If so, how many dependents are there? Are you legally financially responsible for anyone? Does anyone share family financial responsibilities with you?
- Current Debt. How much debt do you have? Do you rent or own? If you own, what is your mortgage? Do you make car loan payments, credit card debt payments, or other payments? If so, is there another policy you have that would cover these payments, like creditor's insurance?
- Lifestyle. What is your current standard of living and what are the costs to maintain it? If you have to scale back, would you, and if so, by how much?
2. Are there any specific things I should consider when choosing my disability insurance?
Yes, there are a number of things you should consider and/or know before you purchase disability insurance -- if you are purchasing it yourself as opposed to your employer providing one standard disability insurance policy for employees. That said, even if your employer provides a standard disability insurance policy, you should still be aware of what the policy says about the following:
- Waiting period is the length of time a person must be “disabled” or off work before benefits accrue. In Canada, it is common to have a waiting period between 3 and 6 months, but some insurance policies can offer shorter or longer periods.
- Benefit period refers to the period your benefits commence (benefit start date) to the time your benefits end. The benefit start date is the first day -- after the waiting period -- you are entitled to receive payment of disability benefits. The benefit period ends the date you are no longer totally disabled or the date you reach a specified age (usually 65 years of age), whichever date comes first.
- Total disability refers to an inability to perform the duties of an occupation. Each disability insurance policy will have its own precise definition of "total disability." If you have long-term disability insurance, then there are generally two categories of total disability. The first is total disability to perform the essential duties of your "own occupation." The second is total disability to perform the duties of "any occupation." The second definition generally applies after the first or second year of total disability.
- Any occupation, at one point, was just that: any occupation, but the Supreme Court of Canada limited this broad use of the term. Regardless what your disability insurance policy's precise language is, the term “any occupation” does not refer to any actual occupation, from a janitor to a CEO position. "Any occupation" must be suitable to any occupation that fits your age, education, work experience, and other relevant factors.
3. What is the role of my disability insurance company?
Your disability insurance company evaluates claims based on the terms of the policy. It will consider the exact terms discussed in question #2. It will also consider medical evidence that supports or fails to support your claim. It will consider if you are indeed incapable of performing your regular occupation or any other similar occupation that meets the qualifications of your education, training and work experience. The disability insurance company adjudicates the claim for benefit; administers the terms of claim including rehabilitation services; and pays the benefit subject to its determination that there is ongoing compliance with the LTD policy. There is an inherent conflict of interest in the roles of the insurance company. This is because the insurance company is making a decision that affects whether the insurance company itself will pay and continue to pay a claim.
4. Do I have to be absolutely disabled to be eligible for disability benefits?
No. The tests for total disability is whether you can work at your "own occupation" or "any occupation." Most people on disability insurance benefits have a reasonable level of functional ability. What they lack is the ability to meet the physical demands of regular full-time employment.
5. My disability benefits have been denied although I am genuinely totally disabled. Why?
Being injured or sick is not the only factor that must be present to receive disability benefits. You must consider:
- If you are a recent employee, there is generally an initial probationary period that applies before you are eligible for the group LTD coverage.
- Many group insurance policies have an initial enrollment period. The insurance coverage must be purchased during this period.
- You may be excluded by a pre-existing condition exclusion. Sometimes a policy will have an absolute exclusion for a pre-existing condition. Other times, the policy will exclude coverage for certain pre-existing conditions until a certain period of time has passed.
- Most policies do not cover self-inflicted harm. Some policies may not cover risky behavior, like skydiving. The cause of your disability can be as important as the extent of your disability.
6. What do I do if my Disability Insurance Benefits are disputed or denied?
The LTD insurer will advise you in writing that your claim has been denied and state the basis for the denial. The insurer will usually advise you that there is a right to submit additional medical evidence or to make an appeal to a higher level decision-maker at the insurance company. It is extremely rare if not unheard of for a higher level decision-maker to allow a claim unless there is additional strong medical evidence supporting the claim. Once you receive the first denial letter, if you have any doubt that you are entitled to benefit, you may have the right to a successful legal claim against the LTD insurer. If your doctor has certified that you are unable to work, you should think twice about accepting an insurer's opinion that you are able to work. At this point, you should consult an experienced insurance dispute lawyer in Newfoundland and Labrador like Geoff Aylward.
7. How long do I have to appeal the Disability Insurance's decision to deny my disability benefits?
The length of time you have to appeal any disability insurance decision is outlined in your disability insurance policy. Technically, the right to sue the insurer could run from a specified time period right from the date of disability (rather than from the date of the denial of the claim). You must be certain that you have time to commence an action against an insurer that may improperly delay or deny your claim. Any question about this can be answered by an experienced disability insurance lawyer like Geoff Aylward. He can provide a proper review of claim deadlines and effectively represent your claim including legal action if necessary.
Geoff Aylward will review the claim documentation and evidence and seek additional support if necessary. He will compile the claim in a persuasive, legally-sound manner that a disability insurance company will find hard to deny.
8. What if I already appealed my disability insurance claim and was again denied?
If you have made one internal appeal with the insurer and that has been denied, the insurer may give the option or impression that you can seek further reconsideration. The appeals process in some respects is just a cat and mouse chase, and the longer it continues the sooner the deadline comes and goes for you to file a lawsuit. Moving forward with constant pleas to the insurer may get you nowhere. You should consult Geoff Aylward first to consider litigation. Geoff Aylward, experienced insurance dispute lawyer, can review your case and provide a winning strategy that effectively ends the rounds of appeal and starts a path to a successful outcome.
9. What is the role of my doctor in a disability insurance dispute?
Your doctor and other healthcare providers, therapists, etc. will provide the information to support your claim of disability. If the disability insurance carrier requires more information, then your doctor will be asked to provide specific information. What the doctor produces will directly impact your disability claim and benefits. Your doctor may also have to provide proof of continuing disability periodically throughout the period you are provided disability benefits. Some insurance policies require that a person is under the ongoing care of a physician to continue to receive benefits. The Newfoundland Courts have dismissed that requirement in cases where ongoing medical care is not going to make a difference in getting back to work.
In some cases, the insurance company may require a designated doctor to examine you.
10. When do I contact an insurance disability lawyer?
Pursuing a disability claim can be confusing and overwhelming. Knowing the meaning of terms, deadlines, and proper organization of the application and supporting materials is of great consequence to the eventual success of your claim. If you want the advice of a knowledgeable legal professional, you can contact Geoff Aylward to review and provide legal counsel on your case generally, the application and appeals process specifically, and to advise when legal enforcement of your claim for disability benefits may be necessary.
You will want an experienced insurance dispute lawyer to help you with the process so that receipt of disability benefits is not put on hold indefinitely (or permanently). There are times an appeal requires new evidence, and Geoff Aylward can determine if it is necessary, or if other steps are required for a successful appeal and legal action. Geoff Aylward is available to his clients when they need him.
The best time to contact a lawyer is when you realize the insurer is raising serious but unreasonable doubts about your disability claim. Generally speaking, an experienced disability insurance lawyer in Newfoundland and Labrador like Geoff Aylward should be consulted before you file an internal appeal with the insurer.
Comprehensive, Resourceful Insurance Dispute Lawyer in Newfoundland & Labrador
Geoff Aylward, Q.C. will provide effective advice and representation in seeking benefit payment or compensation. Contact Disability insurance lawyer Geoff Aylward today either online or at 709-726-7260.