Denied Long-Term Disability: should I go through the internal appeals process or start a legal claim?

By Matt Lalande in Long-Term Disability on August 10, 2021

There is no doubt a very good chance that your disability insurance company (whether Manulife, Canada Life, Great West Life, Sunlife, SSQ, Empire Life, RBC and more…) will try to deny or cut-off or stop payment of your long-term disability benefits at some point within the first two years – or as you approach the two year change of definition.

Adjusters, in our experience, often deny or cut-off long term disability benefits for a variety of reasons, some of which are legitimate reasons and some of which are quite baffling.

For example, long-term disability benefits can be denied or cut-off:

• if your adjuster believes you can “do something” which is not the legal definition of your contract;
• if you do not meet the “total disability test” as set out under your plan;
• if you are not in treatment;
• if you are not following the care of your family doctor;
• if your adjuster feels you are not complying with the terms of the policy;
• if your adjuster relies on a biased medical report from their own doctors on staff or under contract;
• if you adjuster thinks you can work;
• if your adjuster misunderstands your medical condition;
• if there is a delay in applying for disability benefits withing a prescribed time as set out in your policy;

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The Internal Appeal Process

Normally, if you receive long-term disability benefits through your employer’s group benefit plan or through an individual disability insurance policy, you will more likely than not have the option to use your disability insurance company’s internal appeal process or what they won’t tell you – is that you can skip the internal appeals process in it’s entirety and hire an expert disability lawyer to start a legal claim against your insurance company to get your benefits owned and reinstated.

Most disability insurance companies will either strongly suggest or demand that a policy holder file an appeal internally – which, in our experience, never works out in favor of the policy holder. The entire appeals process simply delays your option to hire a disability lawyer to represent you….and even worse, delays the eventual payment of your claim. Every month that a policy holder spends appealing or re-appealing their disability benefits denial internally is a month in which they could be paid.

Should I hire a disability lawyer or file an internal appeal?

The choice is yours – but we recommend a hard no. Remember, an “internal” appeal means that the appeal is done internally – by the same insurance company that denied you in the first place.  There is no outside source involved – the people that already decided are the people that “decide again”. There is no “external” committee involved that would review any new medical evidence – either existing information that your disability insurance company already has or new medical information which you may have submitted in support of your review.  

Even worse, disability companies often make the promise that the internal appeals process is “independent” and that there are “special appeal committees” that are set up to review your appeal in some sort of streamlined fashion – all of which is further from the truth. Disability insurance companies are insurance companies. They are a profit driven business. Profit is not returned when they pay out claims, but rather when they collect premiums and pay out as little amount of claims as possible.

If you are thinking of appealing your claim rather than hiring a lawyer, it is important to understand that realistically, your chances of succeeding with your internal appeal is really quite non-existent. In the past 20 years, we can count on one hand how many successful internal appeals we have seen – and nearly all of these successful appeals involved internal appeals committees correcting course on serious mistakes made by disability claims adjudicators – such as total and complete failure to have reviewed the medical evidence submitted or for failing to ask for updated medical documentation prior to claim denial.

Also, for claimants dragged through internal appeals – the process can be quite draining – psychologically, physically, and emotionally. Many claimants that are cut-off disability and put through the appeals process have no monthly income to fall back on, often give up the fight and end up on social assistance or ODSP at a much lesser monthly amount.

Our suggestion is that you hire a long-term disability lawyer immediately and forget appealing your claim internally. Many claimants get caught in the “appeal and re-appeal” wheel which can take month after month of your insurance company’s own employees and paid doctors reviewing your file.  By hiring our experienced disability lawyers we can get your claim started right away.

What happens if I don’t file an internal appeal?

If you don’t file and internal appeal – our disability lawyers would start a legal claim on your behalf – and move forward – without delay, to litigate on your behalf and collect the benefits you deserve.

We would collect all of the information that we need to start the process, gather all of your medical records in existence and ensure to work with your treatment providers in order to prove that your insurance benefits should not have been denied or terminated. Our job as your disability experts is to legally prove that, on a balance of probabilities, you should be entitled to receive payment of ALL monthly disability benefits owned to date, and that your disability claim should be put back on track and that you start receiving your monthly payment to assist you financially.  We will prove your medical limitations, your functional limitations, your tolerances and exactly why you cannot work – no matter if your issue is psychological, physical or a mental health issue.

If you have questions about your disability claim, our disability lawyers can help.

If you have a question about the internal appeals process – or whether you should hire a long-term disability lawyer, call us today. Talking to us is ALWAYS free and we never charge our clients any money upfront.

We would be happy to speak to you about your disability claim and provide you the proper advice that you need to make the best and most informed decision you can. Call us today no matter where you are in Ontario at 1-844-LALANDE or local in the Hamilton / GTA / Niagara area at 905-333-8888. Alternatively, you can email us through our website and we will ba happy to get right back to you without delay.