How do I know if I have a LTD disability claim?

Have you been unable to work as a result of injury or illness?  Are you a full-time employee of an employer who provides medical/dental and disability benefits? 

If so you may be entitled to apply for long term disability insurance benefits.  

Long-term disability insurance is provided either privately through a policy you have purchased on your own or more commonly as part of a package of benefits provided through your employer.  Long-term disability benefits can be provided by a disability insurance company or may be provided directly by your employer but administered through a separate insurance company as part of an administrative services-only policy.  In that case, the employer is paying the benefit but the insurance company’s staff are assessing and processing the claims.

How to file a claim for long-term disability benefits?

To bring a claim pursuant to a long-term disability benefit policy the claims process begins by completing an application which will be provided either by your employer’s human resource department or by requesting an application directly from the insurance company.  These forms are usually fill-in-the-blanks questionnaires designed to help the applicant explain the nature of the disability and allow the insurer the ability to assess whether the applicant meets the criteria for disability under the policy.

 

What sort of information does the LTD benefit application require?

LTD benefit applications typically require the disabled applicant to complete an application form which describes their employment, the type of disability they are suffering from, their limitations, their medical treatment providers and the sorts of treatment they have been receiving. 

Typically a LTD benefit application will also require a form to be completed by an applicant’s primary care provider, often their family doctor or a specialist.

Typically a LTD benefit application will also require the applicant to sign authorizations to allow the insurer to access additional medical records in order to verify the illness or injury and treatment provided.

What the insurer does with your application

After the application is received, a disability claims adjuster at the insurance company will review the application in consultation with in-house insurance medical experts as part of the long-term disability claims process.  Sometimes additional medical information will be required.  

Sometimes the insurer will require a medical examination to be conducted by an expert of their choice to assess the applicant’s functional status.

Often the insurer will require medical records from prior to the onset of the disability in order to determine whether the disability is one that is covered under their policy, whether it is being actively treated, whether it falls under any of the exceptions listed in the policy, and the extent of the disability.

Do I qualify for long term disability benefits?

The test for qualifying for long-term disability varies from policy to policy based on the insurer and how much you or your employer have paid for the plan. Some policies have very short periods of coverage they provide for and very difficult and high thresholds of disability an employee must meet in order to qualify for the benefit. 

Typically a long-term disability insurance policy provides for coverage from the start of a designated waiting period following the disability until age 65. 

It is common for a disability insurance policy to state that for the first two years following onset of disability that the insured will receive the benefit if they are partially or mostly disabled from their own occupation.  This is sometimes qualified by a percentage of hours or earnings which you have to be disabled from working.  

Following the two-year “own occupation” period many insurance policies state that you will only continue to qualify for the benefit if you are fully disabled from performing any occupation.  The any occupation threshold is more difficult to meet as it requires proof that you not only can not do your former job but also any other job.  

The any occupation test is more nuanced than it seems, however, “Any occupation” is usually interpreted as meaning any occupation that is substantially gainful and in keeping with a person’s education and employment background.  In other words the more education and transferable skills you have the less likely you will be found to be disabled. 

What happens if I qualify for long-term disability benefits?

If you are found to be accepted by the insurer for your long-term disability benefits claim you will of course begin receiving your monthly benefit.  

Your insurer has the right to continue to request medical and personal income information from you however while they are managing your disability insurance claim.  

If you are working part-time or earning other sorts of disability insurance benefits from either Canada pension plan disability or another insurance company you are required to report that. 

If your health improves or deteriorates the insurer is entitled to ongoing medical information to support your claim. 

The insurer may periodically arrange medical examinations for you in order to determine your level of disability.

How is the amount of my long-term disability benefit calculated?

The amount of your benefit is calculated using a formula set out in your insurance policy.  It is often a percentage of your pre-disability income.  It may be taxable or nontaxable based upon the policy purchased by you or your employer.  

All long-term disability benefit insurance policies provide that an insurer may reduce the level of your benefit based on the additional income you earn during the disability period and/or other disability insurance sources like other private policies of disability or Canada pension plan disability.

Taking Action

If you feel you have a valid long or short-term disability claim and you have questions or need assistance at any stage remember to contact the Disability Lawyers at FDT Law at 1-800-563-6348 to get a consultation.