Founder, Lalande & Company Disability Lawyers, Hamilton

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Matt Lalande.

With many working Canadians living paycheque to paycheque, there is no doubt that an unexpected illness, injury or catastrophic medical event can leave many people overwhelmed with financial strain and scrambling to avoid crushing debt. Whether it’s the onset of major depression, cardiovascular disorder, mental illness, serious bodily injury or cancer – coping with the toll of being unable to work and meet financial obligations can be disastrous for many people.

Fortunately, many employees have access to long-term disability insurance, either through their employer via payroll or purchased privately by individuals directly from insurance companies or brokers. The purpose of disability income insurance is to provide periodic payments to a person if he or she is unable to work because of a disability resulting from accident or sickness, provided that he or she meets the applicable policy definition of “total disability.”

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How do you know when to apply for long-term disability?

Think of long-term disability insurance as a type of income-replacement coverage, since technically that’s what it’s designed to do. While none of us anticipate becoming medically incapacitated to the point that we can no longer work, the time to apply for disability insurance is when you can no longer function vocationally because you are hurt, sick or suffering from a serious mentally disability.

Typically, long-term disability picks up where short-term income coverage leaves off. Short-term disability is normally funded by your employer, a short-term disability insurance plan or employment insurance (EI). The period of time between the onset of your disability and when you begin receiving long-term disability benefits is called the elimination, waiting or qualifying period – which is typically 90 to 120 days after you become disabled. If you are still unable to return to work after this time, you will begin to receive long-term disability benefits if you are deemed totally disabled as per your policy definition.

What ‘total disability’ means to a claimant

There are countless policy scenarios, but most long-term disability policies define “total disability” within the first 24 months as being when you cannot perform the important duties of your job, even though you may be able to perform the duties of another occupation.

Typically, after 24 months, there is a “change of disability” definition in most policies that changes the definition of total disability from “own occupation” to “any occupation”, meaning that benefits will continue to be payable only if you cannot, by reason of your education, training or experience, perform the duties of any gainful occupation.

Medical support – the true necessity

It is up to you, along with your medical providers, to prove that you are disabled within the meaning of your policy. Claims involving either invisible (such as chronic pain, mental illness, psychiatric conditions) and objective injuries (injuries that can be seen) both require medical evidence to establish a clear and accurate picture of your clinical condition and tell the tale of why you cannot work.

Disability adjudicators evaluate claims based on the medical evidence provided by your doctors or clinicians on an ongoing basis. It is simply not possible for adjusters to properly adjudicate claim eligibility without your doctor’s records or documentation to rely on. Your own complaints are not sufficient to prove that you are totally disabled. Your medical records must establish the types of impairments that prevent you from working and from which you have been diagnosed by doctors familiar with you and your conditions.

When the disability claim goes wrong

Long-term disability claims can be denied for a myriad of reason – from claimants simply failing to meet the policy definition to fraud, applications or appeals missing deadlines, insufficient treatment compliance, misrepresentation, policy exclusions, insufficient medical evidence or missing medical records. There simply may not be enough medical evidence to support your claim.

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Equally, disability claims can also be unfairly denied or claimants can be cut off their benefits unreasonably and without merit. Disability insurance involves underwriting risk and, because of this, insurance companies tend to operate defensively in order to combat fraud. It is certainly not uncommon for adjusters to unfairly deny legitimate claims without receiving and reviewing relevant medical evidence, relying on doctors considered to be hired-guns, relying on insurance doctors of the wrong specialty, personality conflict between claimant and adjuster, relying on social media or internet investigation, unreasonable surveillance, disregard of your relevant records or by arbitrary internal objective.

Disability insurance is purchased for peace of mind and is meant to mitigate financial risk of unexpected illness or injury. Depending on the terms of your policy, you are entitled to apply for long-term disability if you remain disabled after the elimination or waiting period.

Don’t assume that your adjuster or claims administrator will gather all of your required medical records to support your claim. Adjudicators often manage several dozen claims at once and are not obligated to request records from every clinic you have attended. If you have test results, access to relevant records, imaging (ultrasound, CT, MRI) or any other record you believe supports your disability claim – gather it and send it in. You can potentially shorten your approval time and improve your chances of being approved.

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