Long-term disability (LTD) claims can be complex, and a successful outcome often depends on proper preparation. Insurance companies frequently deny claims due to incomplete paperwork, lack of medical evidence, or procedural mistakes. A skilled LTD lawyer in Toronto ensures that all legal and medical aspects are covered before filing.
Here are the key things a long-term disability lawyer needs to know before making a claim.
1. Understanding the Client’s Medical Condition
A strong LTD claim requires clear medical evidence. Lawyers must thoroughly review the client’s medical history, diagnosis, and treatment records. Key details include:
- The severity and duration of the condition
- How the illness or injury affects daily activities
- Statements from treating physicians confirming the disability
Without proper medical documentation, insurance companies may argue that the client is still capable of working, leading to claim denials.
2. Eligibility Criteria for LTD Benefits
Not all medical conditions qualify for long-term disability benefits. Lawyers need to analyze the insurance policy’s definition of disability. Policies typically classify disability in two ways:
- Own Occupation – The claimant cannot perform their specific job duties.
- Any Occupation – The claimant cannot perform any job for which they are reasonably qualified.
Most policies transition from “own occupation” to “any occupation” after a certain period, which can affect eligibility.
3. Key Deadlines and Filing Requirements
Missing a deadline is one of the main reasons claims get denied. Lawyers must track:
- The policy’s deadline for filing the initial claim
- The time limit for submitting additional medical evidence
- Deadlines for appealing a denied claim
Each insurance provider has specific timelines, and failing to comply can result in automatic denial.
4. Common Reasons for Claim Denials
Insurance companies often deny LTD claims for several reasons. Understanding these common tactics helps lawyers prepare a solid case. Frequent denial reasons include:
- Lack of sufficient medical evidence
- Claims that the client can still perform some type of work
- Surveillance or social media evidence contradicting the disability claim
- Failure to follow prescribed treatments
A long term disability lawyer ensures that all supporting documents counter these common denial tactics.
5. The Role of Employer-Sponsored vs. Private Insurance Policies
LTD benefits can come from either an employer-sponsored group policy or a private policy purchased by the individual. Each type has different claim processes:
- Employer-Sponsored LTD – This may involve additional steps, including coordination with workers’ compensation or employment benefits.
- Private LTD Policies – Usually offer more flexibility but have stricter documentation requirements.
Understanding the type of coverage is essential for navigating the claims process correctly.
6. The Impact of Other Benefits on LTD Claims
Receiving other benefits, such as workers’ compensation or Canada Pension Plan Disability (CPPD), can affect LTD payments. Insurance companies may deduct these amounts from the LTD benefits. Lawyers need to calculate how these offsets impact the final benefit amount.
7. Gathering Strong Supporting Evidence
Besides medical records, additional evidence strengthens a claim. Useful documentation includes:
- Employment records showing work performance before the disability
- Testimonies from co-workers, family, or caregivers
- Functional capacity evaluations assess the claimant’s ability to perform tasks
The more detailed the evidence, the harder it is for insurers to dispute the claim.
8. Preparing for Surveillance and Social Media Scrutiny
Insurance companies often conduct surveillance or monitor social media to find inconsistencies in a claimant’s case. Lawyers should advise clients to:
- Be cautious about what they post on social media
- Avoid activities that could contradict their medical claims
- Understand that insurers may use even minor activities as evidence against them
9. The Appeal Process for Denied Claims
If an LTD claim is denied, the appeal process requires careful legal strategy. Lawyers must:
- Review the denial letter to identify specific reasons for rejection
- Gather additional medical or vocational evidence
- File appeals within the required timeframe
- Prepare for potential litigation if the appeal is unsuccessful
An LTD lawyer Toronto experienced in handling appeals ensures that clients have the best chance of reversing a denial.
10. The Possibility of Litigation
If the insurer refuses to approve a valid claim, litigation may be necessary. Lawyers should be prepared to:
- Negotiate with insurers for fair settlements
- Represent the client in court if required
- Work with medical and vocational experts to support the case
While most LTD disputes settle before reaching trial, having a strong legal approach increases the chances of a favorable outcome.
Final Thoughts
Filing an LTD claim requires careful planning and legal expertise. A long-term disability lawyer must gather solid medical evidence, meet deadlines, and anticipate insurance company tactics. Understanding policy terms, coordinating with other benefits, and preparing for appeals ensures clients receive the benefits they deserve. If you’re dealing with an LTD claim, consulting an experienced LTD lawyer in Toronto can make all the difference in securing a successful outcome.
