Denied LTD due to your insurer’s medical consultant: Next steps

Focused on boosting their bottom line, insurance companies in Canada are constantly looking for ways to turn down legitimate long-term disability (LTD) claims.

A common excuse used to deny claimants access to disability benefits is that the insurer’s medical consultant doesn’t think the individual is disabled.

While the denial can create stress and sleepless nights for claimants in need, it’s important to remember that the decision isn’t final.

If your LTD claim is turned down because your insurance company’s medical consultant doesn’t think you are disabled, there are three things you need to do.

LEARN MORE
• Long-term disability denied in Ontario: Your rights
• What Albertans should do if denied long-term disability
• Denied long-term disability in B.C.: Your next steps

WATCH: Disability lawyers Sivan Tumarkin and James Fireman explain what you need know if your insurer wants you to see their doctor for an assessment on an episode of the Disability Law Show.

1. Confirm that the medical consultant is qualified to comment on your case

In most cases, the medical consultants hired by insurers don’t have the correct expertise to determine if you should qualify for disability benefits. These individuals are usually family doctors or general practitioners.

Some consultants will acknowledge this in their report and recommend that your case is also reviewed by a specialist. However, insurance companies often don’t follow that advice.

• Example: One of the firm’s clients suffered a bad concussion. She had chronic pain, headaches, and psycho-cognitive issues. The report provided by the insurer’s medical consultant commented on her pain and headaches, but recommended that she see a neurologist about her cognitive difficulties. Instead of doing this, the insurance company hastily denied her disability claim. Samfiru Tumarkin LLP took legal action and we were able to resolve her claim for a very favourable amount of compensation.

If your insurer’s medical consultant recommends that a specialist review your case, and your LTD claim is denied before the appropriate specialist can file a report, speak with an experienced disability lawyer at Samfiru Tumarkin LLP.

We can review your situation, assess your legal options, and help you secure the compensation you are entitled to.

SEE ALSO
• Doctor and treating health professional reports
• Disability Law Show: Mistakes people make when denied LTD
• Disability Law Show: Common LTD insurance tactics

2. Seek legal counsel if the insurer’s medical consultant did a paper-review

It’s not uncommon for medical consultants hired by insurance companies to write their reports without speaking to claimants.

Instead of asking you to participate in an in-person or virtual assessment, many rely exclusively on the information included in your medical file. This is called a paper-review.

In most cases, medical consultants don’t do a comprehensive review of your file. They only look at certain aspects before providing their conclusions.

• Example: A construction worker in Toronto filed a long-term disability claim for severe depression. Less than a week after applying for disability benefits, his insurance company informed him that his claim had been denied because their medical consultant didn’t think he was disabled. The worker was confused because he had not been assessed virtually or in-person by the consultant before his LTD claim was turned down. When he followed up on the consultant’s reasoning for why he wasn’t disabled, he learned that they had done a paper-review of his case. He noticed in the consultant’s report that they only focused on the fact that he wasn’t taking antidepressants. However, the worker’s medical file did state that he experienced side effects from the antidepressants he was prescribed and was now participating in cognitive behavioural therapy as an alternative form of treatment.

If your LTD claim is denied for any reason, make sure you get the insurance company’s decision in writing. The denial letter will outline why your claim was turned down.

Once you have the denial letter, gather any other relevant documents (i.e. your policy, application forms, etc.) and contact an experienced disability lawyer at Samfiru Tumarkin LLP.

With this information, our team will be able to identify all of the mistakes that the insurance company made when denying your LTD claim.

SEE ALSO
• Denied long-term disability for mental health issues: Your rights
• Disability in the workplace: Rights for employees

3. Skip the appeals process and file a legal claim

After you have been denied LTD benefits, you will likely receive an invitation to appeal the insurer’s decision. However, you are better off filing a legal claim instead.

Appeals rarely work. In Canada, the appeals process is typically handled by the same insurance company that turned down your claim in the first place.

It’s used by insurers to run out the clock on the two-year window that you have to take legal action after you have been denied disability benefits.

Once the two years are up, the insurance company doesn’t have to pay your LTD claim and you can’t file a legal claim to get the money you are owed.

SEE ALSO
• Disability Law Show: Why you shouldn’t appeal a denied LTD claim
• Disability lawyer discusses Ontario woman’s life insurance denial
• Sun Life reinstates long-term disability coverage after legal action

What should I do if I already appealed?

If you appealed the insurance company’s decision to turn down your long-term disability claim, and were unsuccessful, you may still have options.

As long as it hasn’t been two years since your claim was denied, an experienced disability lawyer at Samfiru Tumarkin LLP can review your situation and help you secure the compensation that you are entitled to.

How we can help

If your long-term disability claim is denied, or you are cut off from your disability benefits, contact the experienced disability law team at Samfiru Tumarkin LLP.

We know the law and regularly resolve LTD, life insurance, and mortgage insurance claim denials across Canada (excluding Quebec).

Several of our lawyers previously worked for insurance companies, which means we know how they operate, why they make certain decisions, and how to enforce your rights.

We have helped thousands of clients, including Julie Austin and Sandra Bullock, hold insurers accountable after their claims were denied or cut off prematurely.

Our disability lawyers provide free consultations and we don’t get paid unless we secure the compensation that you are legally entitled to.