Many long-term disability (LTD) claims in Canada involve detailed medical reviews, policy wording, and insurer assessments. When an LTD application is not approved, insurance companies usually point to specific reasons found in their policies or medical evaluations.
This FAQ explains the most common reasons insurers give when they decide not to approve or continue LTD benefits. The goal is to help you understand the language, processes, and concepts that often appear in claim decisions.
Why do LTD insurers decide not to approve a claim?
Insurance companies review LTD applications using medical records, policy terms, and functional assessments. Sometimes, they determine that the evidence provided does not meet the definition of “total disability” in the policy. Other times, they identify administrative or coverage issues.
These decisions can involve:
- differing medical opinions
- missing or incomplete paperwork
- questions about policy eligibility
- assessments that don’t align with the claimant’s self-reported limitations
Understanding the common reasons listed below can help clarify how insurers evaluate LTD claims.
Common reasons LTD claims are not approved
Here are some of the issues insurers frequently cite:
1. The Definition of “Total Disability” is Not Met
Insurers may say the medical information does not show functional limitations severe enough to prevent you from working in your occupation (or any occupation after the “change of definition” period).
2. Medical Documentation is Considered Insufficient
This may refer to a lack of detailed reports, inconsistent treatment notes, or missing specialist records.
3. Conflicting Medical Opinions
The insurer’s medical consultants or assessors may interpret your medical condition differently from your doctor.
4. Lack of Objective Findings
Some conditions — especially pain-based or psychological — do not always show objective results on scans or tests. Insurers sometimes cite this as a concern.
5. No Formal Diagnosis
If symptoms are present but a clear diagnosis is still pending, insurers may consider the file incomplete.
6. The Insurer Believes You Can Work in Another Occupation
This often appears around the change from the “own occupation” to “any occupation” definition.
7. Non-Compliance with Recommended Treatment
Insurers may note missed appointments, treatment gaps, or declined therapies.
8. Late Application or Missing Paperwork
Deadlines, incomplete forms, and administrative issues are common reasons cited.
9. Surveillance or Activity Reports
Insurers may reference physical activity that they believe does not match the restrictions noted in medical reports.
→ Learn more: Surveillance and Long-Term Disability
10. Findings From an Independent Medical Examination (IME)
An IME may suggest different functional abilities than your own doctor has documented.
11. Pre-Existing Condition Exclusions
Some policies exclude coverage if the condition is linked to symptoms or treatment received in the pre-coverage period.
→ Learn more: Pre-existing Conditions and LTD
These explanations do not always reflect the full picture, but they are the reasons most often listed in LTD claim decisions.
What do these reasons mean in practice?
Insurance companies rely heavily on medical evidence, documented symptoms, and policy wording. When there are inconsistencies, missing information, or differences in medical opinion, they may highlight these as concerns.
Understanding the terminology can help you discuss your file with your treatment providers and clarify what information might be required.
What can you expect in the LTD assessment process?
During an LTD review, insurers typically:
- request medical records and functional assessments
- ask for updates from treating professionals
- use internal medical consultants
- send files for external assessments (such as IMEs or FCEs)
- assess how symptoms impact daily functioning and work ability
- review whether treatments align with clinical recommendations
Each insurer may approach these steps differently, but the overall process generally follows this structure.
If your long-term disability claim has already been declined in Ontario and you’d like to understand how insurers make these decisions, our Long Term Disability Denied Ontario guide provides a detailed overview.