Long Term and Short Term Disability Lawyers

FAQs.

Do I need to be under continuous medical care to receive long-term disability benefits in Ontario?

Yes, to qualify for and continue receiving LTD benefits in Ontario, most insurance policies require you to remain under regular, ongoing medical care for your disabling condition. This demonstrates that you are actively seeking treatment and complying with medical advice to improve your health or manage your condition.

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How long does it take to resolve a long-term disability lawsuit in Toronto?

The timeline for resolving an LTD lawsuit in Toronto can vary depending on several factors, including the complexity of the case, the responsiveness of the insurance company, and whether the matter is settled out of court or proceeds to trial. On average, LTD lawsuits typically take 1 to 3 years to resolve.

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How is long-term disability insurance different from WSIB benefits in Toronto?

When it comes to benefits related to disability and workplace injuries, there is often some confusion between Long-Term Disability (LTD) benefits and Workplace Safety and Insurance Board (WSIB) benefits. LTD benefits are insurance payments provided for individuals unable to work due to non-workplace-related illnesses or injuries and are typically included in employee group benefits plans or purchased privately. WSIB benefits are compensation programs administered in Ontario for workers injured or made ill due to workplace-related incidents, offering support without requiring proof of fault.

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Is there a maximum amount of long-term disability benefits I can receive in Toronto?

Yes, there is typically a maximum amount of long-term disability (LTD) benefits you can receive in Toronto, as it depends on the terms of your specific insurance policy.

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Can I apply for long-term disability benefits in Toronto if I’m already receiving short-term disability?

Yes, you can apply for long-term disability (LTD) benefits while you are still receiving short-term disability (STD) benefits. Many disability insurance plans are designed to transition seamlessly from short-term to long-term coverage, ensuring continuous financial support if your condition prevents you from returning to work.

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What other expenses are involved in an LTD claim?

Apart from legal fees, every case requires that the law firm incur certain expenses. Most expenses in an LTD claim are incurred in obtaining necessary information, including medical records, expert assessments, and reports from physicians and other healthcare providers. 

Other expenses will include court filing fees, process serving fees, and mediator fees. At the conclusion of a successful claim, we will seek to recover the above-mentioned expenses, known as ‘disbursements’, from the insurer. You will be responsible for the portion of expenses that are not recoverable from the insurer. Those expenses will be charged against your settlement or judgment. 

If we are unable to recover compensation for you, you will not be charged expenses.

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How much will my LTD claim cost me?

We will make reasonable efforts to resolve your long-term disability claim as quickly and cost-effectively as possible. 

Our team of  lawyers will review your long-term disability insurance policy when handling your LTD claim. We will also check your collective agreement if you are a union member. 

Additionally, we will look at the insurer’s claim file. We will examine the medical evidence and other facts supporting or weakening your long-term disability claim. We will also address the legal issues that need consideration. 

You usually pay fees, and applicable HST on fees, after the LTD claim ends. Whether you are required to pay fees will depend on the outcome of your claim. If you recover compensation through a settlement or judgment, a money fund will exist and legal fees will be payable out of that fund. If we are unable to recover compensation for you, no legal fees will be payable. 

If you are successful with your claim, the insurance company will pay a part of your legal bill as ‘costs’, effectively reducing the amount of fees that you owe to our firm. 

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What happens if I delay disputing an insurance company’s denial of long-term disability benefits?

If you wait too long to challenge an insurance company’s denial of your long-term disability benefits, you could lose your right to sue the insurer. This is one reason, among many, why it is essential to contact a lawyer immediately following a denial or termination of benefits.

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Can a long-term disability insurance company make me see a doctor they choose for a medical assessment?

Before a lawsuit starts, an insurance company is usually entitled, by the terms of the policy, to request reasonable medical examinations in order to substantiate or refute a claim of disability. 

However, this right has limits. You can ask for help in traveling for an assessment. This includes transportation, meal costs, and overnight hotel stays. 

Even after a lawsuit begins, the insurance company can set up medical assessments. The Rules of Civil Procedure, which dictate how lawsuits are to be conducted, allow specifically for this. 

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Can I claim punitive damages in an LTD case?

It is common for LTD claimants to feel angry, frustrated, disrespected, and mistreated by the insurer that has denied their benefits. They may feel strongly about suing the insurer not only for the denied benefits but for additional damages intended to ‘punish’ the insurer for harsh, harmful or egregious conduct in the way it has handled the claim. Those additional damages are commonly referred to as ‘punitive damages’.

However, our courts rarely award punitive damages in LTD insurance cases. This is because of laws relating to contracts. Even if they seem wrong, insurer's actions generally do not rise to the level required for punitive damages. Moreover, insurers will rarely, if ever, pay punitive damages as part of a settlement of a long-term disability insurance claim.

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If I start a long term disability lawsuit, will I have to go to court?

The majority of lawsuits settle without going to court. Settlements, not court trials, are typically the preferred way to resolve LTD claims, wherever possible, because: 

• Settlements allow the parties to control the outcome of the case and therefore achieve certainty as to outcome, rather than leaving an uncertain outcome to the courts. 

• Settlements can be reached at any time, rather than the parties having to await a potentially costly trial that can be many years away. 

• Settlements remove the risk that the losing party will have to pay the winning party a substantial amount of money in legal costs. 

One crucial, but often overlooked, reason for settlements is that they can include money for future LTD benefits. Trial judges cannot force an LTD insurer pay benefits for the future. Rather, judges only have the power to order the payment of past LTD benefits and interest if the insurer is found to have wrongly denied benefits. Judges can also order the reinstatement of LTD benefits based on the contract terms. Those terms typically speak only to current, not future, entitlement for which the claimant must continuously qualify. 

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How long do I have to file a lawsuit if my long-term disability claim is denied in Ontario?

If your insurance company denies your long-term disability benefits claim, you should immediately talk to a lawyer. Most policies require that you bring your objection to the insurer within 30, 60, or 90 days. 

Policies may require that a lawsuit for denial of benefits be commenced within a year of the denial. The provincial limitations statute that applies to long-term disability insurance claims, however, will typically allow you up to two years to sue the insurer from the denial date. To avoid a problem in this regard, it is best to consult with a lawyer as soon as you are notified by your long-term disability insurer that your benefits claim is denied or is being terminated. 

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Can I appeal a long-term disability denial on my own, or do I need a lawyer?

Yes, you can, but doing so may not be a good idea. When an insurance company denies a claim, it will typically inform you of your right to appeal the decision within the insurance organization itself. You will likely be advised to send to the insurer, at your own expense, further information to support your claim, usually medical documentation.  

In most cases, unfortunately, internal appeals do not result in insurance companies reversing their decisions to deny benefits. Moreover, the time required to start a lawsuit may begin to run from the date of the insurer’s initial denial, while you pursue the internal appeal process, which may be prejudicial to your rights in the event that your appeal is unsuccessful. It is for those reasons, and potentially other reasons as well, that we generally will not recommend that you pursue an internal appeal.

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What possible remedies do I have if my LTD benefits get denied?

LTD lawyers can pursue different remedies for you. These will depend on your particular situation, the LTD contract terms, and what the law allows. 

If your insurer denies your LTD claim at the very outset and you do not receive benefits, it must provide you with reasons. We will need to consider those reasons. The same is true if you received LTD benefits for a period of time and the benefit payments were then terminated. 

If we have serious questions or concerns about how and/or why the insurer responded to your claim in the way that it did, we will discuss next steps with you. This includes the possibility that our firm will be retained by you to investigate a potential legal claim. 

We will inform you if we believe the insurer had a valid reason to deny the LTD claim. We will also let you know if in our opinion the insurer had a valid reason to discontinue your LTD benefits. We may also try to assist by providing helpful advice about any options you may have.

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What should I do if the system initially rejects my long-term disability benefits?

LTD insurance companies can immediately reject your long-term disability claim in certain circumstances. The denial may be because of an injury, condition or illness that the insurer does not accept as genuine or as sufficiently supported by medical evidence.  

Our long-term disability lawyers are well-suited to step in at this point. We have represented many people throughout Ontario who have struggled with their LTD insurance companies. 

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Will I lose my entitlement to long-term disability benefits if my employer terminates my employment?

No. Even if your employer ends your job, you may still get long-term disability benefits as long as you continue to meet the eligibility criteria.  

In contrast, your right to participate in group benefit plans may end if your employer terminates your employment. However, this is separate from your right to continue receiving long-term disability benefits.

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Can I apply for disability insurance without a lawyer?

Yes, you can apply on your own. When you do, however, be certain that your application is supported by strong medical evidence, preferably coming from a medical specialist if possible. If the insurer denies your claim, talk to an experienced lawyer. Getting help from someone experienced is essential. This will allow you to better understand the reason for the denial and, if the lawyer takes your case, the plan will be to examine the shortfalls in your application with a view to building a stronger case.

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What is the difference between "own occupation" and "any occupation" tests?

Every long-term disability insurance policy is different in certain respects. Most policies require that you satisfy the requirements of the “own occupation” test in order to qualify for the first stage of benefits. 

This stage usually extends over one or two years. You will satisfy the occupation test if you cannot perform most of the essential tasks of your regular job, and there is sufficient medical evidence to support your claim in that regard. 

After one or two years, the test to qualify for long-term benefits usually changes, and the requirements to satisfy this stage of benefits will depend on the particular policy. Insurance companies call this the “any occupation” test. 

You may still receive benefits if you can prove, with sufficient medical evidence, not only that you cannot do your own job but also any other job for which you might be suitable by reason of your education, training, or experience. 

It is not uncommon for claimants to lose their benefits when the policy changes from the "own occupation" to "any occupation” stage. It is essential to speak to a lawyer as soon as you receive notification for your disability insurer that your benefits are being terminated because you do not satisfy the requirements under the “any occupation” provisions of your policy.

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Do my long-term disability benefits also cover things like medications and dental treatment?

Most insurance companies do not pay such additional benefits under a long-term disability plan. However, your employer’s group benefits plan will often cover eligible drugs and dental. If you are off work for a lengthy period or time, your employer may stop your coverage or ask you to pay or contribute to the premiums. If your employment ends, you may lose these benefits unless extended by arrangement with the employer.

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Is long-term disability insurance the same as employment insurance (EI) sick benefits?

No, it is not. Employment insurance is a short-term program for people who have paid into it. It helps those who cannot work because of an injury or medical issue. 

The “waiting period” for long-term disability insurance is the period of time that you must wait in order to receive long-term disability benefits. This period is often several months and will vary by policy. Moreover, long-term disability plans may cover you for many years and often provide coverage through age 65.

Employment Insurance has a two-week waiting period. EI sickness benefits may be available up to 26 weeks for financial assistance if you cannot work for medical reasons. As it currently stands, you may be eligible to receive 55% of your earnings up to a maximum of $695 per week. 

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Is long-term disability insurance the same as the Canada Pension Plan Disability?

No, long-term disability insurance, usually provided through private insurers, is not the same thing as the Canada Pension Plan disability insurance. Private insurance companies typically pay benefits based on a set percentage of your wage while disabled. 

The federal government offers the Canada Pension Plan (CPP) disability insurance program. The benefit amount will depend upon the period of time over which you have paid into the CPP program, in addition to meeting the CPP disability criteria.

To qualify for CPP benefits, you must prove a mental or physical disability. The disability must prevent you from doing the essential tasks of your employment, and must be considered severe and prolonged.

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What is Surveillance in Long-Term Disability Insurance?

Surveillance in the context of Long-Term Disability (LTD) insurance refers to the practice where insurance companies may conduct covert monitoring and observation of claimants to investigate the validity of their disability claims. This surveillance is typically carried out by professional investigators who gather visual evidence, such as photographs or videos, to assess the claimant's activities and functional limitations. Here are key points to understand about surveillance in LTD insurance:

• Purpose: The primary purpose of surveillance is to verify the extent of a claimant's disability and ensure that the reported limitations align with their actual activities. Insurance companies use surveillance as a tool to prevent fraud, confirm the accuracy of claims, and protect the integrity of the LTD system.
  
• Activities Monitored: Surveillance may involve monitoring various aspects of a claimant's daily life, including physical movements, interactions with others, engagement in recreational activities, and participation in events that could indicate the level of disability.
  
• Covert Nature: Surveillance is typically conducted covertly, meaning that the claimant is not aware that they are being monitored. This approach aims to capture the claimant's behavior and activities in their natural state without influencing their actions.
  
• Legal Compliance: Surveillance activities must comply with legal regulations and privacy laws to ensure that the rights of the claimant are respected. Investigators must adhere to ethical standards and obtain evidence lawfully.
  
• Impact on Claims: The results of surveillance can influence the outcome of an LTD claim. If the surveillance footage contradicts the claimant's reported limitations or suggests misrepresentation of disability, the insurance company may use this information to deny or terminate benefits.
  
• Frequency: Surveillance is not conducted continuously for all claimants but is often employed selectively based on specific factors, red flags, or suspicions raised during the claims process.
  
• Balancing Privacy and Investigation: While surveillance is a legitimate tool for insurance companies to verify claims, it raises concerns about privacy invasion and the potential misinterpretation of normal activities as evidence of fraud. Claimants have the right to challenge surveillance findings if they believe their disability status has been misrepresented.

Understanding the role of surveillance in LTD insurance can help claimants navigate the claims process effectively, ensure transparency in their interactions with the insurance company, and seek legal advice if they have concerns about the handling of surveillance activities in relation to their disability claim.

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How Much Money Can I Get From My Long-Term Disability Benefits?

The amount of money you can receive from Long-Term Disability (LTD) benefits in Ontario is influenced by various factors, including the terms of your specific LTD policy, your pre-disability earnings, and the duration of your disability. Here are key points to consider regarding LTD benefits in Ontario:

• Percentage of Pre-Disability Earnings: LTD policies typically provide a percentage of your pre-disability earnings as benefits. This percentage can vary but commonly ranges from 50% to 70% of your pre-disability income.
  
• Maximum Benefit Amount: Most LTD policies have a maximum monthly benefit amount, which caps the total benefits you can receive each month. This maximum amount is determined by the terms of your policy.
  
• Duration of Benefits: The duration for which you can receive LTD benefits varies and is specified in your policy. Some policies provide benefits until retirement age, while others have a limited benefit period (e.g., two years, five years).
  
  
• Integration with Other Benefits: LTD benefits may be integrated with other disability benefits you receive, such as Canada Pension Plan Disability (CPP-D) benefits or workplace pensions. The total amount you receive from all sources may be subject to offsets or reductions.
  
  
• Tax Considerations: LTD benefits in Ontario are generally considered taxable income. However, if you paid the premiums for the LTD policy with after-tax dollars, a portion of the benefits may be tax-free.
  
  
• Cost-of-Living Adjustments: Some LTD policies include cost-of-living adjustments to account for inflation, ensuring that the purchasing power of your benefits is maintained over time.
  
• Return-to-Work Provisions: Many LTD policies include provisions for partial disability benefits if you can return to work on a part-time basis or in a reduced capacity. These provisions may affect the amount of benefits you receive.

To determine the specific amount of money you can receive from LTD benefits in Ontario, it is essential to review your LTD policy documents, understand the terms and conditions of the policy, and consult with the insurance provider or a legal expert specializing in disability insurance claims. They can provide detailed information on benefit calculations, limitations, and any additional factors affecting the amount of LTD benefits you are eligible to receive.

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Why Do Insurance Companies Deny LTD Claims?

Insurance companies may deny Long-Term Disability (LTD) claims for various reasons, some of which are legitimate while others may involve errors, misinterpretations, or disputes. Here are common reasons why insurance companies deny LTD claims:

1. Insufficient Medical Evidence: If the medical documentation provided does not sufficiently support the severity or duration of the disability, the insurance company may deny the claim due to a lack of evidence.
   
2. Pre-Existing Conditions: Some policies exclude coverage for pre-existing conditions or conditions that existed before the policy came into effect. If the disability is deemed to be related to a pre-existing condition, the claim may be denied.
   
3. Policy Exclusions: Certain policies have specific exclusions for certain types of disabilities, treatments, or conditions. If the disability falls under an exclusion listed in the policy, the claim may be denied.
   
   
4. Failure to Meet Criteria: Insurance policies often have specific criteria that must be met to qualify for LTD benefits. If the claimant does not meet these criteria, such as the definition of disability or waiting period requirements, the claim may be denied.
   
   
5. Incomplete Documentation: If the required documentation, forms, or information are incomplete, missing, or not submitted within the specified timeframe, the insurance company may deny the claim due to insufficient information.
   
   
6. Discrepancies in Information: Inconsistencies between the claimant's statements, medical records, and other documentation can raise red flags and lead to the denial of the claim.
   
   
7. Failure to Follow Treatment Plans: If the claimant does not follow prescribed treatment plans, attend medical appointments, or comply with rehabilitation efforts, the insurance company may deny the claim on the basis of non-compliance.
   
   
8. Occupational Duties: If the disability does not prevent the claimant from performing the essential duties of their occupation as defined in the policy, the claim may be denied.
   
   
9. Surveillance Results: Insurance companies may conduct surveillance to investigate the validity of a claim. If the surveillance results suggest that the claimant's reported limitations are inconsistent with their activities, the claim may be denied.
   
   
10. Fraud or Misrepresentation: If the insurance company suspects fraud, misrepresentation of facts, or intentional withholding of information by the claimant, the claim may be denied.

Understanding these reasons for denial can help claimants navigate the LTD claims process more effectively, address any issues proactively, and seek recourse if they believe the denial is unjustified. It's advisable to consult with legal counsel specializing in disability insurance claims to explore options for disputing a denied LTD claim.

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What Medical Conditions Qualify for Long-Term Disability?

Long-Term Disability (LTD) insurance typically covers a wide range of medical conditions that significantly impact an individual's ability to work and perform daily activities. While the specific criteria for qualifying for LTD benefits may vary depending on the policy and insurance provider, here are common medical conditions that often qualify for Long-Term Disability coverage:

1. Musculoskeletal Disorders: Conditions affecting the muscles, bones, joints, and connective tissues, such as chronic back pain, arthritis, osteoporosis, and fibromyalgia.
   
   
2. Mental Health Disorders: Including depression, anxiety disorders, bipolar disorder, post-traumatic stress disorder (PTSD), schizophrenia, and other psychiatric conditions that impair daily functioning.
   
   
3. Neurological Disorders: Such as multiple sclerosis (MS), Parkinson's disease, epilepsy, Alzheimer's disease, and other conditions affecting the brain and nervous system.
   
   
4. Cardiovascular Disorders: Including heart disease, congestive heart failure, arrhythmias, and other cardiovascular conditions that impact physical functioning.
   
5. Cancer: Various forms of cancer, including leukemia, lymphoma, breast cancer, lung cancer, and other malignancies that require extensive treatment and cause disability.
   
6. Autoimmune Disorders: Such as lupus, rheumatoid arthritis, Crohn's disease, ulcerative colitis, and other autoimmune conditions that result in chronic symptoms and limitations.
   
7. Chronic Pain Syndromes: Conditions leading to persistent pain and discomfort, such as migraines, complex regional pain syndrome (CRPS), and neuropathic pain disorders.
   
8. Respiratory Disorders: Including asthma, chronic obstructive pulmonary disease (COPD), emphysema, and other lung conditions that impact breathing and physical exertion.
   
9. Endocrine Disorders: Such as diabetes, thyroid disorders, adrenal insufficiency, and hormonal imbalances that affect overall health and functioning.
   
10. Degenerative Diseases: Conditions like osteoarthritis, degenerative disc disease, muscular dystrophy, and other progressive diseases that result in physical decline over time.

It's important to note that each LTD policy may have specific definitions, limitations, and exclusions regarding covered medical conditions. To determine if your medical condition qualifies for Long-Term Disability benefits, consult your policy documents, speak with your insurance provider, and consider seeking guidance from a healthcare provider or legal expert specializing in disability insurance claims.

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Can You Dispute Your Denied Disability Claim?

Yes, you can dispute a denied Long-Term Disability (LTD) claim if you believe that the denial is unjustified or incorrect. Disputing a denied LTD claim involves challenging the decision made by the insurance company and presenting additional evidence or arguments to support your claim for disability benefits. Here are steps to effectively dispute a denied LTD disability claim:

1. Understand the Reasons for Denial: Review the denial letter from the insurance company to understand the specific reasons for the denial. This will help you address the issues raised in your dispute.
   
2. Gather Additional Evidence: Collect any new medical records, test results, physician statements, or other relevant documentation that strengthen your case for disability benefits. Ensure that this evidence directly addresses the reasons cited for the denial.
   
3. Consult with Legal Counsel: Consider seeking advice from a lawyer specializing in disability insurance law. A legal expert can assess your case, provide guidance on disputing the denial, and represent you in negotiations with the insurance company if needed.
   
4. Prepare a Detailed Dispute Letter: Craft a comprehensive dispute letter outlining the reasons why you believe the denial is incorrect. Clearly present the additional evidence, explanations, and arguments supporting your claim for disability benefits.
   
5. Submit the Dispute: Send your dispute letter and supporting documentation to the insurance company within the specified timeframe outlined in your policy. Use a method that provides proof of delivery to ensure your dispute is received.
   
6. Engage in Dialogue: Stay in communication with the insurance company throughout the dispute process. Be prepared to provide further clarification, answer questions, or provide additional information as requested.
   
7. Consider Alternative Resolution: If direct negotiation with the insurance company does not lead to a resolution, explore alternative dispute resolution methods, such as mediation, to seek a mutually acceptable outcome.
   
8. Legal Action: If all attempts to dispute the denial prove unsuccessful, you may consider taking legal action against the insurance company by filing a lawsuit. Your legal counsel can guide you through the litigation process and represent your interests in court.

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How Do I Appeal Long-Term Disability Denial?

When faced with a denial of your Long-Term Disability (LTD) claim, appealing the decision is a crucial step to seek reconsideration and potentially secure the benefits you are entitled to. Here are the steps to effectively appeal a Long-Term Disability denial:

1. Review the Denial Letter: Carefully review the denial letter from the insurance company to understand the reasons for the denial, the policy provisions cited, and any additional information or documentation required for the appeal.
   
2. Gather Supporting Documentation: Collect all relevant medical records, test results, physician reports, and any other evidence supporting your disability claim. Ensure that this documentation addresses the reasons for denial outlined in the letter.
   
3. Understand the Appeals Process: Familiarize yourself with the specific appeals process outlined in your LTD policy. Note any deadlines for submitting an appeal and follow the prescribed procedures to ensure your appeal is considered.
   
4. Draft a Comprehensive Appeal Letter: Prepare a detailed appeal letter addressing each reason for denial, providing additional evidence, explanations, and arguments supporting your claim for disability benefits. Be clear, concise, and organized in presenting your case.
   
5. Seek Legal Advice: Consider consulting with a lawyer experienced in disability insurance law to guide you through the appeals process, review your appeal letter, and provide legal representation if needed.
   
6. Submit the Appeal: Send your appeal letter and supporting documentation to the insurance company within the specified timeframe. Use certified mail or another method that provides proof of delivery to ensure your appeal is received.
   
7. Follow Up and Maintain Communication: Keep track of your appeal timeline, follow up with the insurance company to confirm receipt of your appeal, and maintain open communication throughout the appeals process.
   
8. Consider Alternative Dispute Resolution: If the appeal is unsuccessful, explore alternative dispute resolution options, such as mediation or arbitration, to resolve the dispute outside of litigation.
   
9. Legal Action: If all appeals are exhausted and your claim remains denied, you may consider pursuing legal action against the insurance company through a lawsuit with the assistance of legal counsel.

By following these steps and seeking professional advice where necessary, you can navigate the appeal process effectively and increase your chances of overturning a Long-Term Disability denial.

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What Types of LTD Claims Can I Sue For?

In Ontario, individuals with Long-Term Disability (LTD) claims may have legal options to pursue lawsuits in various situations. Some potential types of LTD claims that individuals in Ontario can sue for include:

Wrongful Denial of Benefits: If your LTD claim is wrongfully denied by the insurance company, you may have grounds to sue for a breach of contract or bad faith denial. This can involve challenging the denial based on policy provisions, medical evidence, or procedural errors in the claims process.

Termination of Benefits: If your LTD benefits are terminated unfairly or prematurely, you may have a basis to sue for wrongful termination. This could include situations where benefits are cut off without proper justification or where the insurance company fails to provide adequate reasons for ending payments.

Breach of Fiduciary Duty: In cases where the insurance provider fails to fulfill its fiduciary duty to act in the best interests of the insured individual, leading to harm or financial loss, a lawsuit for breach of fiduciary duty may be pursued.

Disability Discrimination: If you believe you have been discriminated against based on your disability status in the context of your LTD claim, you may have legal grounds to sue for disability discrimination. This can include situations where you are treated unfairly, denied benefits, or subjected to adverse actions due to your disability.

Violation of Human Rights: If your rights under human rights legislation in Ontario, such as the Ontario Human Rights Code, are violated in relation to your LTD claim, you may have the option to bring a lawsuit for human rights violations.

Bad Faith Insurance Practices: In cases where the insurance company engages in bad faith practices, such as unreasonably delaying or denying valid claims, acting in a discriminatory manner, or failing to adhere to legal obligations, a lawsuit for bad faith insurance practices may be pursued.

When considering legal action related to LTD claims in Ontario, it is advisable to seek guidance from a lawyer specializing in disability law to assess the specifics of your case, understand your rights under Ontario laws, and determine the appropriate course of action to seek redress for any injustices related to your LTD claim.

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What is Disability?

Disability is a broad term that encompasses physical, cognitive, sensory, or mental impairments that may limit an individual's ability to engage in certain activities or perform tasks compared to the general population. Disabilities can be temporary, permanent, or episodic, and they vary in severity and impact on daily functioning.

Disabilities can result from various factors, including congenital conditions, illnesses, injuries, accidents, or age-related changes. The effects of a disability can manifest in limitations related to mobility, communication, cognition, sensory perception, or self-care, affecting an individual's independence and quality of life.

In the context of insurance, such as Long-Term Disability (LTD) coverage, disabilities are typically assessed based on their impact on an individual's ability to work and earn income. Insurance policies define disability criteria to determine eligibility for benefits, considering factors such as medical evidence, functional limitations, and the individual's capacity to engage in gainful employment.

Understanding the nature of disabilities, their diverse manifestations, and the challenges they pose to individuals is crucial for creating inclusive environments, providing appropriate support and accommodations, and promoting equal opportunities for individuals with disabilities in various aspects of life.

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What happens if you cannot work due to symptoms of long-haul COVID?

During the pandemic governments created benefits programs for people who could not work due to COVID infections. As these programs wound down, a person experiencing long-haul COVID would likely need to apply for disability benefits through their employer's health insurance policy, they own policy, or though the Employment insurance disability benefits program.

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What are long-haul COVID symptoms?

Common symptoms include: fatigue (including chronic fatigue syndrome); shortness of breath or difficulty breathing; cough; joint pain; chest pain; memory, concentration or sleep problems; muscle pain or headache; fast or pounding heartbeat; loss of smell or taste; depression or anxiety; fever; dizziness when you stand; worsened symptoms after physical or mental activities. Symptoms may be new onset following initial recovery from an acute COVID-19 episode or persist from the initial illness. Symptoms may also fluctuate or relapse over time.

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What is long-haul COVID?

Long-haul COVID occurs in individuals with a history of probable or confirmed SARS CoV-2 infection, usually 3 months from the onset of COVID-19 with symptoms and that last for at least 2 months and cannot be explained by an alternative diagnosis.

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Why are long term disability claims related to mental health sometimes denied?

As an "invisible" disability, diagnosing and assessing the severity mental illnesses often requires medical providers to consider an individual's self-reported symptoms. Insurers seeking to validate disability claims may their own doctors to review an individual's medical history, require new testing or assessments, and may conduct surveillance to determine if an applicant is as disabled as they claim. Sometimes insurers will use information or alternative opinions in these new findings as a basis to deny a claim.

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What if I cannot work due to a mental illness?

Beyond using regular sick days, many people draw on short-term disability benefits if their symptoms prevent them from working for weeks at a time. Generally these benefits cover between 60 to 100 percent of your salary or average pay for up to six month to a year and they are paid from an employer’s plan or from Employment Insurance sickness benefits. If you still cannot return to work after the short-term disability benefits ends, you may be able to receive long-term disability benefits.

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What are some common symptoms of mental illnesses?

Symptoms common to more than one type major mental illness include: Fatigue; changes in eating habits; changes in sleeping patterns; lack of interest in previously pleasurable activities; distancing yourself from others; inability to maintain peaceful relationships with loved ones; extreme mood swings; unusual anger; sadness; irritability; confusion or fright; memory problems; unwanted memories/flashbacks or persistent thoughts; unexplained pain or body aches; substance abuse; suicidal thoughts; hearing voices that are not there.

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What are some of the most commonly reported mental illnesses?

Some of the most commonly reported mental illnesses include: Attention Deficit Disorder (ADD) and Attention Deficit Hyperactivity Disorder (ADHD), anxiety (generalized anxiety disorder or social anxiety disorder), bipolar disorder, depression (persistent depressive disorder or major depressive disorder), eating disorders (anorexia, bulimia, Binge Eating Disorder (BED), Compulsive Over Eating (COE), etc., Obsessive-Compulsive Disorder (OCD), Post-Traumatic Stress Disorder (PTSD), schizophrenia.

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What is mental illness?

A mental illness or mental disorder is a condition that can cause changes in cognition, behaviour and/or emotion. Although brain-based, these conditions can also result in debilitating physical symptoms, including reduced energy levels, sleep disturbances and chronic pain.

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When do I need a long-term disability lawyer?

A long-term disability insurance policy should be something you can rely on, although this is not always the case. If you or a family member is unable to work for an extended period due to an accident, illness, or injury, we recommend that you consult with a personal injury lawyer as soon as possible. A personal injury lawyer can help determine if you have a potential long-term disability claim against your insurer and advise you on how best to appeal if your long-term disability insurance claim is denied.

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What if I belong to a union?

In some cases, a lawsuit against the disability insurer may not be available to you. The only recourse you may have is to file a formal grievance if you are a union member. Therefore, it is important to advise our long-term disability lawyers whether you belong to a union as part of your employment. If you do, the terms of the collective agreement between your union and your company will need to be reviewed to determine whether the grievance procedure is the ‘exclusive remedy.’

If the collective agreement appears to make your employer the party responsible for payment of long-term disability benefits, the long-term disability claim will likely have to be ‘litigated’ using the union grievance apparatus.

On the other hand, if the terms of the collective agreement require only that your employer pays the long-term disability insurance coverage premiums to a disability insurer, or if the collective agreement is silent regarding long-term disability insurance, the likelihood is greater that you will be able to bring a lawsuit against the disability insurer for its denial of long-term disability benefits.

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Can a long-term disability insurance company force me to see a doctor of their choice for a medical assessment?

Before litigation commences, an insurance company is entitled to take reasonable steps to continue to determine whether or not you remain eligible for benefits. They are therefore entitled to request reasonable medical examinations. However, this right has limits.

Further, if you are asked to travel for an assessment, you are entitled to ask for assistance, such as transportation, meal expenses, and even hotel accommodation if an overnight stay is required.

After the lawsuit starts, the insurance company is permitted to arrange medical assessments in accordance with the Rules of Civil Procedure that govern the conduct of lawsuits.

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Is it true that if I start a lawsuit, the insurance company might hire a private investigator to conduct surveillance?

Yes, however, there are privacy and other rules about how and where a private investigator can conduct surveillance involving an individual. It is essential to consult with a lawyer and ensure that neither the insurance company nor the private investigator exceeds permissible boundaries.

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What if my long-term disability benefits are denied?

When you have filed your claim, your insurance company may give you the green light to receive your long-term disability benefits. However, it is important to know that long-term disability insurance benefits may terminate because you now fall under a change in the definition of disability after a certain period of time has passed.

A two-year period is the general cut-off mark, signalling a change from being unable to work “your own occupation” to being unable to work in “any occupation”. The moment your long-term disability benefits stop, you need to call a lawyer. It is not up to your long-term disability insurance company to ultimately decide when your long-term disability benefits end.

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Do I stop being entitled to long-term disability benefits if my employer terminates my employment?

No. Even if your employer terminates your employment, your entitlement to long-term disability benefits will continue as long as you remain eligible since your disability arose while you were covered as an employee.

In contrast, your right to participate in group benefit plans may end if your employer terminates you. However, this is separate from your right to continue receiving long-term disability benefits.

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How long is the insurance company obligated to continue to pay me long-term disability benefits?

There are generally two broad restrictions on how long an insurance company is obligated to continue to pay you long-term disability benefits.

• The first is based upon entitlement.
  
  To receive benefits, you must continue to meet the disability tests under the applicable own occupation or any occupation provisions.

• The second restriction is related to time or age.
  
  Every contract for long-term disability insurance is different. Some contracts are time-limited; that is, they will only provide benefits for two years, or five years, or ten years, regardless of your age. Almost all contracts are also age-limited. Nearly every agreement in Canada provides for the entitlement to continue to receive long-term disability benefits as long as you qualify for benefits or until you reach the age of 65, whichever comes first.

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Are my long-term disability benefits taxable?

Whether or not your long-term disability benefits are taxable depends on who pays the premiums. In cases where an employee pays the premium by having it deducted from his or her paycheque, any future disability benefit that is received should not be taxable. However, if an employer pays the premium for your long-term disability benefits, the government and the courts will generally consider that benefit a taxable one.

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How much money do long-term disability insurance policies pay?

Long-term disability insurance typically pays a percentage of your wage, subject to a specified maximum. A common percentage is somewhere between 60% and 70% of your regular pre-disability salary.

As there are many different kinds of long-term disability insurance policies, it is essential to understand the terms of your specific coverage. For instance, some policies will include coverage for overtime you worked before you became disabled, while others will only pay you a percentage of your regular wage.

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Can I apply for disability insurance by myself, or do I need a lawyer?

You can generally apply for disability insurance benefits by yourself. If you are worried that there might be some reason that the insurance company will dispute or deny your claim, such as a pre-existing medical condition, or disputed diagnosis, it may be beneficial to consult with a lawyer early on to discuss how to best present your claim.

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What is the difference between the “own occupation” and “any occupation” test when determining whether you qualify for disability benefits?

Every long-term disability insurance policy is different. However, most policies require that you satisfy the “own occupation” test to qualify for the first stage of benefits, usually lasting one to two years. Generally speaking, you meet the own occupation test if you are unable to perform substantially all of the important elements of your regular occupation.

After one or two years, again depending on the policy, the test to qualify for benefits usually changes to what insurance companies refer to as the “any occupation” test. Under that test, you may be entitled to continue to receive benefits if you can establish, on the strength of the medical evidence you submit to the insurer, an inability not only to perform your own occupation but any other occupation for which you are reasonably suited by education, training, or experience.

It is not unusual for claimants to have their benefits terminated once the policy transitions from the “own occupation” to the “any occupation” standard. It is essential to consult with a lawyer as soon as you receive a letter from an insurance company indicating that it intends to terminate your benefits due to the change in entitlement definition from own to any occupation.

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Does my long-term disability benefit also cover things like medications and dental treatment?

Most insurance companies do not pay such additional benefits under a long-term disability plan. However, your employer’s group benefits plan will often cover drugs and dental.

After you have been away from work for an extended time, employers may either discontinue your participation in the group benefits plan or require you to pay the premiums for your coverage. If your employment is terminated, your eligibility to participate in the group benefits plan will typically end.

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What is the difference between short-term disability insurance and long-term disability insurance?

Short-term disability benefits are available to you soon after you have become disabled. In general, the waiting period for applying for short-term disability benefits is between 0 and 2 weeks. An insurance company can provide short-term disability benefits, but more often, such benefits are paid by your employer directly.

Long-term disability benefits, on the other hand, usually only commence following a three to six-month waiting period and may be payable for months or even years, depending on the nature of your disability.

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Is long-term disability insurance the same as employment insurance sick benefits?

No, it is not. Employment insurance sick benefits is a short-term insurance program offered to claimants who have paid into the employment insurance program and are prevented from working at their occupation due to injury or medical condition. The waiting period under private or group long-term disability insurance (that is, the period you must wait before you are eligible for benefits) is often several months and varies based on the policy.

Moreover, long-term disability plans may cover you for many years and often provide coverage through age 65. Employment Insurance has a two-week waiting period. And then you were entitled to receive benefits for only 15 weeks. However, the federal government has recently signalled its intention to increase unemployment insurance sick benefits coverage from 15 to 26 weeks.

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Is long-term disability insurance the same as Canada Pension Plan disability?

No, long-term disability insurance is not the same thing as the Canada Pension Plan disability insurance. Private insurance companies typically offer long-term disability insurance under a contract with your employer to pay you a fixed percentage of your wage while you are disabled. The federal government offers the Canada Pension Plan (CPP) disability insurance program. It pays a certain amount considering the period over which you have paid into the CPP program. To be eligible for CPP benefits, you must have a mental or physical disability that regularly prevents you from doing any type of substantially gainful work, have a disability that is prolonged or of indefinite duration, or is likely to result in death. 

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What kinds of disabilities do long-term disability insurance policies cover?

When people experience physical disabilities, it is generally easier to “see” the disability. Wearing a cast, using a walking aid such as a cane or walker, or having visible scarring are some examples of objective signs of disability. When a disability is not evident, such as mental health and chronic pain, it is harder to prove that an individual is suffering or incapable of working.

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What are some common long-term disability policy terms?

Although each individual policy has unique terms and requirements, there are four general criteria an long-term disability policyholder must meet to qualify for benefits:

• The claimant has a serious physical or mental condition;
  
• The condition in question is expected to last for at least one year or longer;
  
• The condition in question impairs the claimant’s ability to perform the duties of their current job;
  
• The claimant is up-to-date on paying their policy premiums.

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What is a long-term disability insurance policy?

Long-term disability policies exist to protect individuals who are unable to work due to a disability or illness by providing an income replacement benefit after regular sick leave and short-term disability benefits are exhausted. If you cannot work due to illness, accident, or injury for an extended period, you may qualify for long-term disability benefits through your employer's insurer or through your own private policy. Every long-term disability insurance policy is different.

To qualify for long-term disability benefits, you will have to meet the eligibility criteria outlined in your policy. This will include meeting the definition of “disability” that is described in your insurance policy and whether your disability prevents you from returning to your job or "any job".

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Do I need a disability lawyer?

If the following two scenarios sound familiar, then you may need a long-term disability lawyer:

1. Your insurance claim for long-term disability benefits was originally approved by your insurer, paid for some period, and then denied or terminated.
2. You have been fighting with your long-term disability insurer for months or even years over its denial of your long-term disability claim, and you have gotten nowhere but frustrated and sick.

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