If your long-term disability claim is denied by your insurance company, you have the right to appeal this decision. Your appeal is an internal process within the insurance company. Although appealing the insurance company’s decision may seem like the easiest option, appeals often fail due to vague and inconclusive medical information. Without providing a substantial amount of new medical evidence, the original decision will most likely be maintained. The appeal process can also be quite lengthy, thus extending your time without disability benefit payments.
A second option is to discuss the matter with a disability lawyer and bypass the insurance company appeal process by suing the insurance company. When presented with a lawsuit, an insurance company will either start paying your benefits, agree to a settlement, or let a court decide whether you are entitled to benefits. Legal action takes the decision away from lower-level claims managers and pushes the matter forward to more senior members of the insurance company who are experienced at dealing with disputed claims. Suing your insurance company forces them to take your disability claim seriously.
If you decide to go through the insurance appeal process, the following steps should be taken to strengthen your appeal.
Internal Appeal Process
1. Identify the Deadline Appeal
If you get a letter from the insurance company denying your claim, the appeal deadline is usually included in the last few paragraphs of the letter. If the insurance company didn’t send a denial letter, then you need to ask them to put the denial in writing. The appeal deadline will either be in the form of a specific date or a given number of days from the date on the denial letter.
2. Enforce Your Employment Rights
Upon denial of your claim, the insurance company will most likely notify your employer that you are able to work and that you don’t qualify for long-term disability. You need to inform your employer, in writing, that you are appealing the insurance company’s decision and that you are still unable to work. Your employer will most likely allow you to stay on unpaid sick leave while waiting for your appeal decision.
However, if your employer chooses to rely on the insurance company’s opinion and demands you return to work, you need to have your doctor write a new sick note. It is important the new sick note clarify you are still unable to work, regardless of the insurance company’s opinion. The updated sick note will trigger your rights to ongoing accommodations under Employment and Human Rights laws.
3. Gather Documents Needed to Plan Your Appeal
- The denial letter from your insurance company
- A copy of your group insurance booklet, which describes your long-term disability benefits
- A copy of the insurance company’s “claim file”
- A copy of your union’s collective agreement (if applicable)
- A copy of your family doctor’s and specialist’s (if applicable) medical file, going back to when your symptoms
started to affect your work
4. Analyze the Denial Letter and Identify Documents Needed for The Appeal
Insurance companies are required to provide, in writing, the reasons for denying your claim. In some circumstances, they will even list specific documents or information they need to reconsider their decision. This can certainly aid your appeal as you will know exactly what information needs to be provided.
Claims are often denied due to vague and inconclusive medical information. Providing missing medical information or medical documents to the insurance company will greatly increase your odds of overturning the insurance company’s decision. The following is a list of information that should be provided to your insurance company upon appeal.
- Clarified medical diagnosis
- Clarified functional limitations
- Clarify the symptoms and limitations that prevent you from doing your job
- Clarify information about your job requirements or physical demands
- Make sure to provide clinical reports and records from specialist treatment providers other than your family doctor. (physiotherapy, surgeon, chiropractor, etc.)
5. Prepare and Send Your Appeal Letter
Although important, the appeal letter is not as determinative as one may think. At this stage, the insurance company mostly bases its decision on the medical records and opinions you have supplied.
Your appeal letter only needs to do three things:
- Say that you are asking for an appeal
- Attach the required documents in support of your appeal
- Arrive at the insurance company before the deadline.
A response usually comes within 30 to 60 days.
There are multiple options one can explore once their claim for short-term disability benefits is denied. In analyzing the following options, it is important to really assess how injured you are and if you really need short-term disability benefits.
1. Go back to work
There is always the possibility that the reason your short-term disability claim was denied is simply because you are well enough to work. This is a true self-evaluation option. If you really feel you are unable to work, then move on to appealing the denial of your claim. If not, you may be saving yourself quite a bit of trouble returning to work.
2. Appeal the denial
The appeal process for short-term disability benefits mirrors that of the long-term disability process established above. If your insurance company denies your appeal, then move on to the following options.
3. Apply for EI sickness Benefits
If your short-term disability appeal is denied, but you are not well enough to return to work, then your next best option is to apply for Employment Insurance (EI) sickness benefits. They will pay you 55% of your pre-disability weekly income for up to a maximum of 15 weeks.
4. Apply for long term disability benefits
If you are still not able to work after the 15 weeks, then you can apply for long-term disability benefits. You should apply for long-term disability benefits even though your short-term disability claim was denied. While it is very likely your long-term disability claim will also be denied, you need the application and denial to happen, so you have more options.
5. Appeal the long-term disability denial
This has a low chance of success as you will need new information or medical information that has not already been provided to the insurance company.
6. File a lawsuit against the insurance company
If the insurance company denies your long-term disability claim, and you are still not able to work, then your next step is to file a lawsuit against the insurance company.