Do I need a positive PCR test for COVID-19 to get disability benefits?

The lack of PCR testing should have no real impact on whether a long-term disability (LTD) claim is successful.

With the shortage of PCR tests and the rapid spread of the Omicron variant, many are concerned that their inability to confirm COVID-19 through a positive PCR test will prevent them from getting approved for LTD benefits if they remain disabled from work.

Diagnosis not a prerequisite to getting LTD

A diagnosis of COVID-19, or any diagnosis, is not a prerequisite to getting LTD benefits. Look at the language of any standard LTD policy and you will find nothing requiring a diagnosis. Instead, the test for LTD benefits simply requires one to suffer from a disability that prevents them from performing their own occupation. The focus is on the claimant’s functional ability, not their diagnosis (or lack of diagnosis).

Sivan Tumarkin, a Toronto disability lawyer and co-founding partner at Samfiru Tumarkin LLP joins Bill Carroll on Newstalk 580 CFRA to answer questions about whether claimants will have to be able to prove they have long-term COVID-19 in order to receive disability benefits.

Indeed, there are thousands of people that suffer from mysterious ailments that are, at present, beyond the capacity of medical science to diagnose and treat.  Even if an individual has not (yet) received a diagnosis, that doesn’t change the fact that they are disabled from work and are entitled to benefits. The courts have consistently recognized this fundamental aspect of disability insurance policies.

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On a more practical level though, a lack of a PCR test is, in all likelihood, irrelevant for an LTD claim. While a positive PCR test would confirm COVID-19 at that moment, in most LTD cases, you are not entitled to receive benefits until after you have been disabled for a predetermined waiting period, usually 4-6 months.  Even if you are initially disabled by COVID-19 from work, it is highly unlikely that you would still test positive for COVID-19 by the time the waiting period is finished, and benefits become payable. While there are numerous reported cases of “long COVID” or “long-haul COVID”, there is no medical test to confirm one has long COVID, or that one’s symptoms are tied to a previous positive PCR test.

For those that are suffering long COVID that did not have access to a PCR test (or failed to get one for whatever reason), it is possible that an insurer may include a lack of confirmed PCR test within their reasons for denying a claim. While this is unfortunate, it is also almost certainly the case that the insurer would still have denied the claim even if there had been a positive PCR test several months before. However, if an insurer is relying on the lack of PCR test in their adjudication of a claim, this can easily be challenged in a legal claim.

How do I know if I qualify for LTD benefits?

Anyone who is covered under an LTD policy that has contracted COVID-19 and continues to suffer symptoms that prevent them from working indefinitely is entitled to disability benefits, whether or not they have had a PCR test that confirms their COVID-19.

How can a long-term disability lawyer help me?

If you have long-haul COVID and your insurer is denying your claim, call us at 1-855-821-5900 for a 100% free consultation. You can speak to an experienced long-term disability lawyer, find out your rights, and get the answers you need.