Possible Reasons Your Long-Term Disability Claim May Be Denied in Nova Scotia

If a serious injury, physical illness, or mental condition prohibits an employee from performing their job for a substantial period of time, they may be eligible to collect long-term disability benefits. These benefits may be available to eligible individuals who are insured through their employer’s group plan, or who pay premiums for their own private insurance policy that covers long-term disabilities. If eligible, individuals whose medical conditions prevent them from earning a living may also be able to receive compensation from the Canada Pension Plan (CPP).

Long-term disability benefits are designed to compensate eligible policyholders with a portion of their salaries if serious medical conditions lead to their prolonged absence from work. In most cases, these benefits only become available after policyholders have collected payments from all other available sources of compensation, such as paid sick leave, vacation time, and short-term disability benefits. In Canada, long-term disability plans usually replace between 60-70% of a recipient’s normal income. This monthly source of income replacement can provide a degree of financial stability during what may otherwise be a chaotic and uncertain period of time.

However, even if you believe your condition qualifies you to receive long-term disability benefits, an insurance provider may deny your claim for a variety of reasons. In Nova Scotia, claims for benefits are commonly denied for the following reasons:

Medical Conditions Do Not Meet the Plan’s Definition of Disability 

In Nova Scotia, eligibility requirements for long-term disability benefits vary between insurance policies. This means that different policies offered by the same insurance company may have different definitions of disability.

One of the most common reasons why claims for long-term benefits are denied is that an applicant’s medical condition does not fall under their policy’s definition of a disability. In these cases, even though an individual may be unable to perform the duties of their job as a result of their physical injury, illness, or mental condition, their claims for benefits may be denied.

Although, ultimately, an individual’s eligibility to collect benefits will be determined by the terms of their insurance policy, some medical conditions that may qualify them for long-term disability benefits include:

• Heart disease
• Back problems
• Chronic pain or complex regional pain syndrome (CRPS)
• Lupus or Lyme disease
• Psoriatic arthritis or fibromyalgia
• Depression
• Bipolar mood disorder
• Post-traumatic stress disorder (PTSD)
• And possibly more

Many insurance policies stipulate that, in order to receive long-term disability benefits, a policyholder’s condition must prevent them from performing activities related to their current job. This is the definition of disability for the first 2 years after the accident, once you start collecting LTD. This is often referred to as the “own occupation” stage. Usually, after this initial period of 2 years has expired, the definition of disability changes to include a requirement that the medical condition must prohibit the applicant from completing the tasks of any job, even if it is unrelated to their current position.

When providing definitions of medical conditions that may be considered disabilities, insurance policies may use language that is difficult to interpret. If you are unsure if your illness or injury meets your policy’s definition of disability, a Nova Scotia disability lawyer may be able to review your insurance plan and help explain its eligibility requirements.

Missing Records and Insufficient Proof

In order to apply for long-term disability benefits, an individual may be required to submit medical documentation proving that their condition will prevent them from returning to work for a lengthy period of time. Supporting documents such as medical records, physician testimonies, and the results of medical examinations may help applicants substantiate their claims for long-term disability benefits.

Oftentimes, benefits claims in Nova Scotia are denied because of missing or insufficient medical documentation. If the medical records you provide to your insurance company do not adequately illustrate the full extent of your disability, your claim may be denied.

Additionally, insurance companies often require proof that an individual applying for long-term disability benefits is receiving ongoing, regular medical treatment for their disabling condition. As such, including sufficient evidence that proves you’ve been under a physician’s regular care may increase your chances of your claim being approved.

In cases where claims for long-term disability benefits are denied because of missing records or insufficient proof of disability, a Nova Scotia disability lawyer may advise you to file an internal appeal directly through your insurance provider. Providing your insurer with updated information and additional supporting documentation may help overturn their initial decision.

Pre-Existing Conditions and Elimination Periods

Pre-existing conditions are medical diagnoses that policyholders have received before they enrolled in their current insurance plans. When signing up for insurance coverage, individuals may be asked to disclose any pre-existing conditions they may have experienced.

Depending on the terms of your policy, if you are unable to work because of an illness or injury that was caused by a pre-existing condition, you may not be eligible to collect long-term disability benefits.

Some policies offer elimination periods for pre-existing conditions. In those cases, a policyholder with pre-existing conditions must be enrolled in their insurance plan for a set period of time before they become eligible to claim long-term disability benefits.

If your claim is denied because your insurance company believes your disability was caused by a pre-existing condition, a disability lawyer may be able to review your medical history and compile evidence to try disproving their determinations.

What To Do if Your Claim Has Been Denied

While insurance companies are not obligated to share precise information about claim denials with the public, it can be determined that the majority of claims for long-term disability benefits in Canada are not approved. When an application is rejected, a claimant should be notified of the decision in writing. In this notification letter, insurance companies should provide the claimant with detailed information about why they do not meet the qualifications required to collect benefits.

If your claim for benefits has been unfairly denied, a Nova Scotia disability lawyer may be able to help you appeal the insurance company’s decision. In cases where additional supporting documentation may clarify a technicality that led to a denied claim, a lawyer may be able to help their client by compiling a thorough portfolio of medical evidence to include in their appeal.

However, if the insurance company’s decision was determined by other factors that cannot be substantiated by providing additional documentation, a disability lawyer may be able to file an external appeal against the insurer on their client’s behalf. After filing a lawsuit against an insurance company for an unfairly denied benefits claim, the decision to grant long-term disability benefits would be determined by an external arbitrator, and not the insurance company.

If the external appeal is successful, a Nova Scotia disability lawyer may be able to help their clients recover damages for:

• Previously denied benefits payments
• Legal fees
• Damages for mental stress experienced
• Punitive damages
• And possibly more

Call Preszler Injury Lawyers Today

If a severe medical condition such as an injury or illness prevents you from earning a living, and your claim for long-term disability benefits has been unfairly denied, Preszler Injury Lawyers may be able to help you appeal the insurance company’s decision.