A long-term disability claim denied in Ontario should be reviewed against the policy wording, medical evidence, insurer reasons and applicable time limits. Keep the denial letter and claim file, and consider an internal appeal or other process where appropriate. This guide explains the common issues and next steps.
Key takeaways: Preserve the policy and denial letter, request the claim file, collect supporting medical records and calendar any applicable deadlines.
Approval is not the end of the process
An approval letter is an important step, but it means little until benefits actually start being paid at the expected amount. Policies commonly require ongoing proof of disability, and the insurer may ask for updated medical information, forms from treating doctors, or attendance at assessments.
Offsets can reduce the benefit, sometimes to zero
Most LTD policies reduce the monthly benefit by other disability income the claimant receives or is entitled to receive. Common examples include Canada Pension Plan Disability benefits, workplace insurance benefits and certain other benefits. Depending on the policy, offsets can reduce the LTD payment substantially, or even to zero.
Offsets can also create overpayments. If a claimant is awarded CPP Disability benefits retroactively, the LTD insurer may demand repayment of the amount it paid during the same period. Many policies require claimants to apply for CPP Disability. Reading the policy’s offset clause is important.
Why approved claims are cut off
LTD benefits can be terminated after approval for various reasons, including:
• surveillance that the insurer says is inconsistent with the claimed limitations;
• new medical records or assessment reports;
• a change in the definition of disability after a set period, for example from being unable to do your own job to being unable to do any job for which you are reasonably suited (depending on the policy);
• a pre-existing condition exclusion, where records suggest the condition existed before coverage began;
• a failure to provide requested information or attend an assessment.
Reading the denial letter
A denial or termination letter should explain the reasons. It may also describe an internal appeal process and any deadlines. Read it carefully and keep a copy. Letters sometimes state that an internal appeal is optional or describe how it interacts with the right to sue, which can be important for timing.
Time limits
Time limits for LTD claims can be complex. Under Ontario’s Limitations Act, 2002, the basic limitation period for a claim is generally two years from discovery. In LTD cases, the start date may be disputed and policy terms, appeal correspondence and the facts can all matter. Because missing a limitation period can end a claim, the deadline should be reviewed promptly after a denial. See https://www.ontario.ca/laws/statute/02l24.
Delay and financial pressure
LTD disputes can take time to resolve. For a person without income, delay can create significant financial pressure, which may affect decisions about whether to accept a settlement. Understanding the policy, the evidence and the likely timeline early can help people make informed choices.
Steps after an LTD denial
• Request a complete copy of the policy and your claim file, including medical reports relied on.
• Note every deadline mentioned in correspondence.
• Ask your treating doctors for detailed records that address the insurer’s reasons.
• Continue appropriate treatment and keep records of appointments.
• Be mindful that surveillance and social media may be reviewed.
• Get legal advice about the limitation period before pursuing an internal appeal.
LTD and other claims
An LTD claim may exist alongside other claims, such as a personal injury lawsuit after a car accident, accident benefits, or CPP Disability. These claims interact, including through offsets and deductions, and coordinating them can affect the overall result.
Group and individual policies
LTD coverage is commonly provided through an employer’s group benefits plan, but some people buy individual policies. Group policies are usually governed by a master policy between the employer and the insurer, and employees often receive only a booklet summarizing the coverage. When a dispute arises, the full policy wording is what matters, so it is important to request it. Individual policies may have different definitions, exclusions and application questions. If the insurer relies on a pre-existing condition clause or an alleged misrepresentation on an application, the wording of the policy and the application will be central.
Medical evidence
LTD disputes often turn on medical evidence. Clear, detailed records from treating doctors explaining a claimant’s restrictions and limitations, and how they affect the specific duties of their job or other jobs, can be more helpful than brief notes stating that the person is unable to work. Claimants can ask their doctors to address the specific reasons given in the denial letter.
Conclusion
A long-term disability claim denied in Ontario should be reviewed promptly against the policy and evidence. Contact Booni Law at admin@boonilaw.com or +1 (226) 271-1751 to discuss the documents. No outcome is promised.
Frequently Asked Questions
Can I sue my LTD insurer in Ontario?
Generally, yes, an LTD claim can be pursued in court if benefits are denied. Time limits apply and should be reviewed promptly.
How long do I have to sue after an LTD denial?
The basic limitation period under Ontario’s Limitations Act, 2002 is generally two years from discovery. In an LTD claim, when discovery occurred can be disputed; get advice early. See https://www.ontario.ca/laws/statute/02l24.
Why did my LTD benefit go down after I got CPP Disability?
Many LTD policies offset CPP Disability benefits, and a retroactive CPP award may lead to an overpayment demand.
Should I do the internal appeal first?
It depends on the policy and the timing. An internal appeal may not stop the limitation period, so get advice before relying on it.
Has your LTD claim been denied or cut off?
If your long-term disability benefits have been denied, reduced or terminated, Booni Law can review your policy, the denial letter and the time limits that may apply. Email Booni Law at admin@boonilaw.com or call +1 (226) 271-1751. No particular outcome can be promised.
Disclaimer: This article is provided for general informational purposes only and does not constitute legal advice. Reading this article does not create a solicitor-client relationship between you and Booni Law. The information in this article may not reflect the most current legal developments and should not be relied upon as a substitute for professional legal advice tailored to your specific circumstances. If you require legal advice, please contact Booni Law.
