Disability/Personal Injury

Totally Disabled: What does it mean in an LTD claim?

Total disability definition

The term “totally disabled” or “total disability” means that an employee can’t perform the essential duties of their job because of an illness or injury. If that is the case, the individual should be able to apply for and receive long-term disability (LTD) benefits.

It does not mean that someone has to be completely unable to do anything in order to receive LTD. You don’t need to be paralyzed to qualify for payments. Total disability is a term that was created by insurance companies to mislead people and prevent them from applying for LTD benefits, and taking money out of the insurers’ pockets.

WATCH: Disability lawyer Sivan Tumarkin, co-founding partner at Samfiru Tumarkin LLP, explains the myths surrounding total disability on an episode of the Disability Law Show on Global and CTV.

In a famous Supreme Court of Canada ruling (Paul Revere Life Insurance Co. v. Sucharov), Chief Justice Laskin explained that total disability should not be taken literally. He stated:

“The test of total disability is satisfied when the circumstances are such that a reasonable [person] would recognize that he should not engage in certain activity even though he literally is not physically unable to do so. In other words, total disability does not mean absolute physical inability to transact any kind of business pertaining to one’s occupation, but rather that there is a total disability if the insured’s injuries are such that common care and prudence require him to desist from his business or occupation in order to effectuate a cure; hence, if the condition of the insured is such that in order to effect a cure or prolongation of life, common care and prudence will require that he cease all work, he is totally disabled within the meaning of health or accident insurance policies.”

Am I totally disabled if I can do some work?

Even if you are able to do some of the tasks of your job, you can still be considered to be “totally disabled” and qualify for LTD benefits. You could even be able to work part-time and still qualify for LTD. Your ability to work in and of itself does not disqualify you from being totally disabled.

How does the insurance company know if I’m totally disabled?

Your insurance provider will do an assessment of your ability to do the work that your own occupation requires. This will take place when you initially apply for LTD benefits. The results of the assessment will determine if you qualify for LTD payments.

Total disability after two years

After you have been on LTD benefits for two years, the insurance company will change their assessment of your capabilities from “own occupation” to “any occupation.”

Own Occupation vs. Any Occupation

Long-term disability policies typically refer to two definitions when assessing an employee’s ability to work when suffering from a disability: they are own occupation and any occupation.

  • Own Occupation: An employee can’t handle the key aspects of their job when they are totally disabled because of an injury or illness. This applies at the outset of an LTD claim.
  • Any Occupation: An employee is totally disabled and unable to perform any job that they have qualifications for. Qualifications are based on the person’s experience, education, training and skillset. It also strictly applies to work that would generate at least 60% of your previous income. This is typically applied when a claimant hits the second year of their LTD benefits.

When the two-year mark hits, the insurance company may make you attend a skills assessment. The purpose of this test is to give the insurer a chance to build a case to cut you off of LTD payments. If your condition shows that you are still totally disabled, the insurer will have to continue to pay you benefits – something that insurance companies do not want to do.

LISTEN: Disability lawyer Sivan Tumarkin explains what happens to your LTD claim and the test for total disability when you hit the two year mark, on the Disability Law Show.

What should I do if I am denied because I’m not “totally disabled?”

You should contact a long-term disability lawyer at Samfiru Tumarkin LLP immediately if your LTD claim is denied because the insurance company says you’re not totally disabled.

The purpose of insurance is to give you peace of mind. It is there to provide a safety net in the event that you are too ill or injured to work. Insurance companies often pull the trigger too quickly and deny or cut off long term disability payments to individuals who are down on their luck; they need help to get better so they can return to work, not another knock against them.

Insurers often deny LTD claims inappropriately just to save money. Their main goal is to generate profits and make their shareholders happy. They do this by refusing to provide compensation to people who need the financial support to survive when they are too sick to work.

The insurance company has to listen to your doctors if they support the idea that you are too ill or injured to work. Their medical support and documentation form the basis of your claim.

Common reasons for denial of LTD
Frequently used long-term disability terms
FAQs on LTD claims and denials

Should I appeal my LTD denial?

You should not appeal the insurance company’s decision if you are denied LTD benefits. In our years of experience, appeals rarely work and are often unsuccessful. You are asking for a second opinion from the insurance company that denied you in the first place!

Insurers use the appeal process to wear you down and run out the two-year clock on your ability to file a legal claim for compensation.

How can a disability lawyer help?

A disability lawyer at Samfiru Tumarkin LLP can help you with your LTD claim in many ways. These include:

  • Gathering and preparing the correct medical documentation for your claim.
  • Guiding you on your application for LTD and navigating the process after your application is approved.
  • Reviewing you situation if you are denied LTD to determine if your insurer is in breach of your policy.
  • Working with your doctors to make sure there is solid support for your claim.
  • Contact the insurance company on your behalf so you don’t have to deal with the stress.
  • Working to get you the compensation you are legally owed by your insurer.

How can we succeed if the insurance company denies my LTD claim?

Our firm has helped many disabled individuals across Canada (including Ontario, Alberta and B.C.) successfully challenge insurers’ denial of LTD claims. Our success comes from three things:

  • We provide the necessary medical documentation that supports our client’s disability to the insurance company.
  • We speaking the language of the insurer to make sure that the interpretation of the disability policy is accurate and just.
  • We don’t give your insurer leeway. We make it clear that either the disability policy is upheld and payments are made, or we use the full force and weight of the law to force them to pay.

The result is always positive for our clients. A disabled person is owed this compensation and there is no reason why the insurance company should keep that money. You may be David and the insurance company is Goliath, but always remember who won that battle.

Has Samfiru Tumarkin LLP helped others with LTD claims?

The long-term disability lawyers at Samfiru Tumarkin LLP have years of experience working on behalf of clients to get compensation for LTD denials. Some of our lawyers once worked for insurance companies; we know the tricks that insurance companies use to convince you to walk away from your rights – and how to use the law against them to get what you’re owed.

Some of our successful cases against insurance companies have been reported by various media outlets. These include our claim against Sun Life on behalf of Sandra Bullock, as well as teacher Julie Austin’s fight with OTIP and Mitch Murphy’s case against SSQ over their policy.

As Canada’s largest and most positively reviewed employee-side disability and employment law firm, we are uniquely positioned to help you with your long-term disability claim. Our lawyers provide free information on LTD through various radio and TV shows. Our team has helped tens of thousands of Canadians get the advice they need, the compensation they deserve.

Denied or cut off LTD?

We will answer your questions, and help resolve your long-term disability claim quickly and with little to no stress.

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