Toronto Disability Lawyers
Have you applied for or been denied disability insurance benefits? Beyond the physical pain, you may be going through, having a claim rejected, delayed, or prematurely terminated can burden you and your loved ones with undue stress and anxiety. Too often, injured and disabled people with legitimate claims are denied the benefits they are entitled to under their policies due to technicalities, oversight, lack of proper documentation, or other bogus reasons—and the impact is disastrous. Fully or completely unable to work and without access to these benefits, it can quickly become difficult to support a family and obtain crucial care.
Whether you are filing for the first time or already dealing with a claim denial, do not give up. At Auger Hollingsworth, our experienced disability lawyers regularly help clients get the insurance benefits they deserve. With extensive knowledge of Toronto laws and the disability benefits filing process, we employ whatever legal tools necessary to help you get the support you need: providing airtight evidence of your injury or illness and treatment requirements, thoroughly investigating the reasons for denial, and filing successful appeals. If necessary, we are even prepared to bring legal action against the insurance company to claim your rightful benefits along with any arrears (back pay) you may be owed.
Practice Areas
Common issues with disability claims in Toronto and what to do if yours is denied
It’s important to remember that insurance companies are first and foremost businesses, meaning that their goal is always to pay out as little as possible on every claim. They may create policies filled with confusing, obtuse language, impossible deadlines and requirements for documentation, and dozens of other opportunities for them to reject claims. But denial of your initial claim, whatever the justification, should not discourage you from pursuing the benefits to which you are entitled. With support from a reliable disability lawyer from Auger Hollingsworth, you can feel confident that your claim contains all the details and requirements needed for it to be approved—or that if denied at first, you have plenty of options to proceed and gain approval through an appeal or another legal process.
What types of coverage are included in private disability insurance plans?
Private disability insurance policies—whether group/employer-provided or privately purchased—typically include three types of coverage:
- Sick leave – Sick leave benefits generally amount to your full pay for a short, fixed time period, typically a few days to a few weeks.
- Short-term disability (STD) – Short-term disability coverage may or may not be included in your employer-provided policy. If so, it will kick in once you exhaust your sick leave runs and can last for around six months, providing 60-85% of your wages over the determined time period on an employer-provided policy (or more or less according to your private plan’s details). Even if your employer does not provide STD coverage, you may still be entitled to short-term sickness benefits under the federal EI program.
- Long-term disability (LTD) – Plans with LTD protect you for at least up to two years after your STD benefits run out, typically providing up to 80% of your wages if you continue to be unable to return to work at your job. If, after two years, your disability or illness is such that you cannot return to any work at any job, your LTD policy may allow you to collect disability benefits until you reach 65 years old.
Do I need to purchase disability insurance?
Not everyone needs to purchase their own disability insurance. If your employer provides a robust plan, for example, paying for a private policy on top of that would not only cost you unnecessarily but also serve little purpose beyond redundancy. Conversely, under certain circumstances you should absolutely purchase disability insurance:
- If your job does not provide any coverage
- If your job provides coverage that is lacking
- If the group coverage available to you through a professional membership or union is inadequate or unaffordable
- If you are self-employed
The self-employed stand to gain the most from purchasing their own plans, as they can arrange not only for coverage of lost wages but also for benefits that cover deferred income taxes, loan obligations, overhead costs, and other business expenses in the event that they suffer a debilitating injury or condition.
What is disability insurance and what plans are available to me in Toronto?
Disability insurance is a type of insurance coverage that supplements your income in the event that you become injured, chronically ill, or otherwise unable to work. As benefits are determined based on salary or wages, only employed persons in Toronto can purchase a disability insurance policy.
Depending on the nature of your work and eligibility, you might obtain benefits through government insurance programs or through private plans. Government disability insurance coverage is available through the province of Ontario’s Workplace Safety and Insurance Board (WSIB), through federal Employment Insurance (EI), and, for those who qualify, through Canada’s Pension Plan (CPP). Both the WSIB and CPP programs also provide certain benefits for the family and other dependents of the policyholder.
Private disability insurance policies may be available through a group plan provided by your employer or purchasable through your union or professional organization or individually purchased directly from an agent or insurer itself. In the case of some employer-provided group disability insurance plans, you may see deductions on your paycheck to help contribute to your premiums. But only the portion of the benefits your employer pays for are taxable; you will not owe taxes on any premiums you pay.
Individual disability insurance policies are also available for anyone to purchase privately. There are many reasons you may choose to purchase an individual plan, such as if your employer-provided coverage is inadequate, if your employer does not provide disability coverage at all if the group plans are available to you via other sources (unions, professional organizations, etc.) are unaffordable, or if you don’t have a direct employer. Individual disability plans allow policyholders to have the utmost control over the coverage they carry, and they offer portability—in other words, the plans are not tied to a specific employer. For this reason, many Canadians enjoy the peace of mind and flexibility of private individual plans.
In this second part of a 3-part interview personal injury lawyer Brenda Hollingsworth describes what steps to take after an Ontario motor vehicle accident.
Get a FREE assessment from us here https://ahinjurylaw.com/
Are you looking for expert advice after an accident? The smartest step you can take after any accident is to connect with a personal injury lawyer for a FREE consultation.
In Ontario, Canada, Personal injury lawyers Brenda Hollingsworth and Richard Auger with their team of experienced lawyers offer FREE, no-pressure, advice about your rights and entitlements when you have been hurt.
For more information on whether you have a claim for car accidents, motorcycle accidents, bicycle accidents, any other road accidents, accidents at work, slips and falls, etc, go to https://ahinjurylaw.com/
The interview also discusses what information you should collect at the accident scene before you leave. Get the other driver’s name, address and driver’s license. Wait for the police if they have been called.
It is also important to get medical attention as quickly as possible. It is easier to prove your injury was caused by the accident if you see a medical doctor as soon as possible after the accident.
Requirements for receiving LTD benefits
Requirements for receiving LTD benefitsProving that your injuries or illness led to “total disability” is the most important factor for receiving benefits. However, there are some other steps you may need to take to receive LTD benefits from your insurance policy. They include:
- Not letting your insurance lapse while you are trying to receive disability benefits. Make sure you keep paying premiums to keep your insurance.
- In some instances, proving that the injury or illness was not a pre-existing condition.
- Proving that you were a full-time employee at the time your injury or illness occurred.
- Making sure that your injury or illness is not excluded from your insurance policy.
Since each insurance company has its own requirements for being eligible for Long Term Disability benefits, it’s best to have an attorney help you through the process.
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Consult an experienced lawyer for help with your Toronto disability claim
Whether you are considering your options for purchasing disability insurance, getting ready to file a new disability claim for benefits, or have already had your claim denied at least once, you need a legal professional by your side with a deep understanding of the insurance industry and a proven track record advocating for people with disabilities. At Auger Hollingsworth, our lawyers work tirelessly to protect our clients’ interests. To learn more about how we can help you, call 1-888-574-4529 or contact us online and schedule a free assessment of your case today.
More Information
For more information, visit one of our blog posts:
- De-Mystifying Long-Term Disability
- What’s the Difference Between Short-Term and Long-Term Disability?
- Do I Need Individual Disability Insurance If I’m Covered By My Group Plan?
- Want to Know More About How To Apply for LTD Benefits?
- What to Keep in Mind When Making an LTD Claim
- Want to Know What to Expect When You Hire a Disability Insurance Lawyer?
- Can an Insurance Company Follow and Videotape Me if I Made a Long-Term Disability Claim?
- I’m Receiving Long-Term Disability Benefits; Can I Still Work?
- I Suffer from Chronic Pain and Was Denied Long-Term Disability Benefits
- Is My Depression Considered a Disability?
- See lawyers Richard Auger and Brenda Hollingsworth talk to Jeff Hopper about your right to disability insurance in this video.
Long-Term Disabilities Denials FAQs
Long-term disability (LTD) occurs when a person is injured or sick to the point that he or she is unable to return to work.
LTDs can result from car accidents, slip and fall injuries, workplace injuries or any other type of serious accident.
It is at such times that people rely on insurance – but claiming rightful compensation and benefits for LTDs can be complex.
By their nature, long-term disability claims involve significant sums of money and, as such, many are denied. Denials of long-term disability claims can cause serious distress to families.
Whether you are facing difficulties in proving that you qualify for benefits or benefits have been stopped after a period, you may find some answers to your questions below.
If your application for long-term disability is denied or your benefits are stopped, you will be informed in writing by the insurer.
As part of your notification, you should be informed about how to “appeal” the decision. The key thing to bear in mind is that this appeal is not like a standard legal appeal held in front of a panel of arbitrators or judges. The decision will be made by the same insurance company (and maybe even the same group of people) that denied your claim in the first place.
This means that the success rate of such appeals is very disappointing.
Disability insurance is not all geared around long-term disabilities. It is important to know what type of policy you have and what you are covered for.
The main four types of disability insurance in Ontario are the following:
- Long-term disability insurance (LTD)
This is like income protection insurance. If illness or disability renders you unable to return to work, you will be paid a portion of your income. This can help with living expenses, medical treatment, rehabilitation, and so on.
Coverage is normally provided for two years, after which time you are expected to take up any occupation for which you are reasonably qualified (or could become qualified for). Failure to do so can see the withdrawal of long-term disability benefits.
- Short-term disability insurance
This is also a form of income insurance protection, providing income replacement if you are unable to work due to a medical condition or injury.
It is usually purchased by employers on behalf of employees but applies regardless of where an injury occurs – it does not have to be in the workplace. Payments are generally made only for the first 120 days of a medical issue.
- Critical illness insurance
Critical illness insurance covers you if you are diagnosed with a serious illness such as cancer, stroke, heart disease, heart attack and generally around 10-15 other serious medical conditions.
This cover is paid in one lump sum and is not dependent on whether you return to work or not.
- Disability mortgage insurance
If you become disabled and unable to earn an income, disability mortgage insurance ensures that you have the financial support to pay your mortgage.
It generally includes up to a certain amount every two weeks or month and limits on the duration of payments may apply.
With long-term disability denials, you can be informed that you do not qualify for benefits from the beginning or that you no longer qualify for benefits after a certain period.
Some of the most common reasons for denying claims include:
- Injury or condition not considered restrictive enough
You may be informed that your medical condition or injury is not considered serious enough to prevent you from going to work or is excluded from coverage as per the terms of the insurance policy.
Before accepting your claim, the insurance company will assess the limitations and restrictions caused specifically by your injury. The loss adjuster will decide whether your injuries are serious enough to prevent you from doing your job and this will largely depend on medical reports and the opinion of medical professionals.
- Lack of medical evidence
Some conditions (and their symptoms) such as psychological conditions, brain injuries or chronic medical conditions like fibromyalgia or chronic fatigue syndrome, have few visible symptoms.
Standard types of imaging diagnostics or blood tests do not identify such conditions and so evidence of symptoms must be documented in medical reports. Otherwise, the insurance company can deny your claim based on a lack of medical evidence.
- Material misrepresentation or non-disclosure
Insurance companies frequently attempt to void policies for material misrepresentation (providing incorrect information) or non-disclosure (not telling them key information), thereby invalidating a policy.
A good example might be a pre-existing health condition that should have been declared before the policy was set up.
- Failure to pay premiums
If your policy has lapsed due to non-payment of premiums, you may be ineligible for long-term disability coverage.
- A review of your case after surveillance
Some insurance companies hire private investigators to conduct photograph, video, and social media surveillance without the claimant’s knowledge. Within limits, this is legal and is done to try to catch claimants doing things that they say they can’t do (and therefore undermine their credibility and their claim).
As long as your claim is genuine and you have reported the truth, there is nothing to worry about. Surveillance will not help the insurance company.
However, if the evidence gathered contradicts your version of events, the insurer may deem you able to work and deny your claim or discontinue benefits.
- Breach of a rehabilitation clause
Most long-term disability policies have a rehabilitation clause.
This means that LTD benefits are paid as long as you get appropriate treatment for your condition from a qualified physician. Failure to do so may be deemed a breach of the clause and provide an excuse for the insurance company to terminate benefits.
If your long-term disability claim is denied, you can appeal but, for reasons covered in the question above, appeals rarely work.
Alternatively, you can hire a lawyer and make a legal claim against the insurance company.
Once we start the legal process, the insurer is forced to defend the legal claim, which incurs significant costs.
Often, the insurance company wants to avoid the extra costs associated with a court case (including legal fees and punitive damages) and will negotiate a settlement with the claimant out of court.
Taking legal action is, therefore, often a preferable course of action to lodging an appeal.
If an injury or medical condition prevents you from working or performing the tasks required by your current job, your long-term disability insurance policy should cover you regardless of the type of injury or condition.
Check your policy to see if it excludes certain illnesses or injuries compensable under a Workplace Safety Insurance Board claim through your employer.
Long-term disability policies vary in their terms but most last until 65 years of age and some have maximum periods for payment of LTD benefits, such as five or 10 years.
Most policies will pay up to two years if you are unable to return to your place of work (the own occupation test), after which you are expected to take up any employment in any occupation for which you are able.
If you can show that you are unable to work anywhere, benefits may continue according to the terms of your policy.
You have certain responsibilities during an LTD claim and these should be made clear to you in the approval letter you receive from the insurance company.
You must follow the responsibilities outlined or the insurance company may repudiate your policy and deny or discontinue coverage.
Generally speaking, these responsibilities include:
- Making best efforts to recover from your injury or condition – including following all medical advice
- Meeting with a rehabilitation consultant to prepare you for return to work and making best efforts to do so
- Making best efforts to abide by a return-to-work plan with modified duties
- Making best efforts to pursue benefits from other sources, e.g., Canada Pension Plan (CPP) Disability Benefits and to keep the insurer advised of progress
- Advising the insurer of any reportable income, e.g., CPP Disability Benefits, WSIB payments, severance payment, self-employment income, etc.
- Advising the insurance company of any overpayments made to you
- Advising the insurance company of changes to your health condition
If you have sustained injuries requiring long-term disability benefits and have been denied coverage in Ontario, start by discussing your case during a free case evaluation with a personal injury lawyer at Auger Hollingsworth.
