Illness is a part of everybody’s life. According to CBC, Canadians averaged 9.5 days off per year due to illness or disability in 2020. But what happens when you can’t return to work? It’s a prospect most of us don’t want to think about, but there’s help available through long-term disability insurance.
The income protection that you receive when you apply for Long-term disability insurance, offers the safety net you need when you can’t go back to work, but claiming it is often fraught with headaches and stress. In this guide, we’ll show you how to prove long-term disability, so you receive the benefits you deserve.
What is Long-Term Disability Insurance?
Long-term disability insurance is a form of income protection that will replace anywhere from 60% to 85% of your pre-disability salary, up to a maximum amount. Generally, it continues to pay out until you can either return to work or reach retirement age.
The 2022 Canadian Survey on Disability states that 27%, nearly eight million Canadians aged 15 and above, have some form of disability that limits their daily activities.
It’s estimated that at any given time, up to 12% of the Canadian workforce is off work due to injury and is receiving some form of benefit, whether that’s long-term disability or workers’ compensation payments.
How Does Long-Term Disability Insurance Work?
Long-term disability benefits require you to prove that your current condition meets the threshold for a long-term disability. It requires comprehensive medical evidence, including diagnostic reports, treatment plans, and medical evidence from your doctor or a specialist.
Before you start receiving payments, there’s a waiting time, known as an elimination period, of 90-180 days from when your disability was diagnosed. During this period, you’ll have to rely on other benefits, like short-term disability, savings, and employment insurance.
Generally, the process goes like this:
- Complete the insurer’s claims forms and submit them for review
- Wait for the insurer to get back to you. They often ask for extra information, like additional medical information or functional abilities assessments
- If approved, you’ll receive monthly benefits as a percentage of your pre-disability income, depending on your specific policy. These benefits may be taxable, depending on how your premiums were paid
- Respond to regular updates that your insurer might request to confirm nothing has changed about your disability status
How to Prove Long-Term Disability in Canada
Proving long-term disability in Canada is an uphill struggle. Insurers are notorious for doing everything possible to preserve their bottom lines and deny as many cases as possible. Even with strong evidence, benefits are denied all the time.
According to industry statistics, roughly 60% of long-term disability claims are denied every year for one reason or another. Stats Can is also reporting growing mental health-related disability claims. Why does this matter? It means there are more disability benefits claimants than ever, and insurers have responded by tightening their requirements and even resorting to predatory practices to deny the benefits you’re entitled to.
Now, every insurer is entitled to set their own requirements for long-term disability benefits. However, the two things in common to every insurer are that successful claimants need are:
- A medical diagnosis from a qualified healthcare professional, including your condition and its impact on your ability to work
- Proof of a treatment plan and that you’re adhering to that treatment plan to manage your condition. This matters because it shows you’re committed to your recovery
Types of Evidence to Prove Your Long-Term Disability Claim
Long-term disability claims rely on medical evidence obtained from a qualified medical professional. It’s the foundation of any legitimate claim, and without it, your claim will be denied. It’s the leading reason these claims are rejected.
Evidence you should provide includes:
- Statement – A statement from the physician most familiar with your condition detailing your condition and its impact on your ability to work
- Treatment Records – All treatment records from any hospital you attended and any medical professionals involved in your care. That might include your usual GP, specialists, and psychiatrists
- Laboratory Test Results – Include laboratory tests, including biopsies, ECGs, and blood work
- Imaging Studies – Add in different imaging studies, such as CT scans, MRIs, and X-rays
- Expert Reports – Assist your claim by getting reports from each specialist you’ve been working with to provide an insight into your condition from every angle, including psychiatrists, surgeons, and other specialists
You can never have too much evidence to show your side of the story. Even for those who are struggling with undiagnosed symptoms, something like a doctor’s note or a prescription for painkillers helps to address any potential reason why an insurer might look to deny your claim.
The Importance of High-Quality Medical Evidence for Successful Long-Term Disability Claims
Medical evidence is designed to be objective yet detailed. Unfortunately, a doctor’s word isn’t law, and a note that says you’re unable to work isn’t going to unlock disability benefits like it might satisfy an employer when you need a week off work.
But what constitutes a high-quality evidence package? Generally, your evidence should tell the insurer the following:
- The nature of your injury/illness with a formal diagnosis (if one exists)
- The type and severity of your symptoms
- How long you’ve been experiencing those symptoms
- Clinical observations
- The extent of your functional limitations, like the tasks you can’t perform and how they connect to why you can’t work
- Prognosis and timeframe for recovery
- Recommended treatment plan
- How your treatment plan has impacted your condition
- Confirmation that you’ve followed your treatment plan
- Pre-existing conditions
Other Supplementary Evidence to Support Your Claim
Medical evidence might be the foundation of your claim, but there’s non-medical evidence that provides more perspective into your case. That includes the context of your disability and its impact on your life. After all, the medical perspective can only tell you so much. Here are some examples that can help you prove your disability and its extent:
- Employer Letters – Obtain a letter from your employer about how your disability impacts your ability to work
- Personal Journal – Document your own experience of your diagnosis, treatment, and disability to provide further insights into how your day-to-day life has been impacted
- Employment Records – Attach your previous work history and how much you were earning in the past. It shows how the disability has impacted you financially and also helps to show that your claim is legitimate
What to Do If My Long-Term Disability Claim Has Been Denied?
A denied claim is the norm for the majority of claimants initially, but that does not mean you are ineligible for benefits. It simply means you must go the extra mile to further prove the legitimacy of your disability. Here’s how to go about confronting a denial of your claim.
Review Your Reason for Denial
By law, insurance companies must issue a formal letter explaining why your claim has been denied. Examples of the most common reasons for denial include:
- Insufficient medical evidence
- Failure to meet the policy’s definition of disability
- Missing documentation
Understanding the reasons for your denial provides the basis for your next steps.
Source Additional Evidence
One way of overturning a claim denial is to supply extra medical evidence and other forms of documentation in an appeal. It confronts practically every reason for denial and can prove that the insurer was wrong in their rationale and reasoning.
Extra evidence may include new diagnostic tests or statements from your healthcare providers. It’s also worth mentioning to your healthcare providers that you are applying for these benefits and providing them with the reasons why your claim was rejected. This can help them supply evidence and statements that directly address the insurer’s reasons for their decision.
The appeals processes aren’t standardized across insurers. Every insurance company is entitled to define its own appeals process and deadlines. Take the time to read through your policy documents and denial letter for information on what you must do to appeal and the deadline to do so. If you fail to register your appeal before the deadline, you could lose the right to contest the insurer’s decision entirely.
Canadian law does not put the final decision and right to contest it in the hands of individual insurers. Instead, you have the legal right to appeal your denied claim, but also to file a lawsuit against the insurance company, with the support of an experienced disability lawyer. With over 35 years of experience in disability law, we do not recommend taking on appealing your case alone.
Hiring an experienced disability lawyer will give your claim the best chance of success.
How a Lawyer Helps You Prove Your Long-Term Disability Claim
Disability lawyers know all the tricks that insurers employ to get out of following through on the obligations stated in their policies. Filing a lawsuit means you will also come up against their legal teams, fighting tooth and nail to prevent you from succeeding. Working with a lawyer is about so much more than filing paperwork. Some of the functions they perform when fighting in your corner include:
- Gathering evidence
- Organizing up-to-date documentation to build the most compelling case possible
Consulting independent medical experts to offer additional insights into your condition - Reviewing your insurance policy to ensure compliance
- Dealing with all insurance company communications, taking this burden off your plate
- Identifying and acting on bad-faith strategies employed by the insurer.
- Supporting you throughout the process
The large majority of cases are settled favourably during mediation. However, if your case does not settle at mediation, a lawyer by your side provides you with the expertise needed to properly prepare for the various legal procedures and processes you’ll come up against to win your claim.
At Share Lawyers, we know what it takes to win disability benefits cases. For over 35 years, we have tackled Canada’s leading insurers, including Sun Life, Manulife, Canada Life and RBC Insurance. If you’re worried about your family’s financial security, rest assured that we can support you in rebuilding your life so you can focus on your health.
Schedule your free consultation with an experienced disability benefits lawyer, and let’s tackle Canada’s biggest insurers to get what you’re entitled to together.
