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Denied Disability : The Internal Appeal Process vs. Hiring a Disability Lawyer

By Matt Lalande in Long-Term Disability on October 14, 2021

Denied Disability : The Internal Appeal Process vs. Hiring a Disability Lawyer

From our practice, we have seen that many disability carriers will tend to deny long-term disability payments as the claimant approaches the change of definition at the 24 month mark. For claimants, it is important to understand this so you can avoid being caught off guard when you get the dreaded denial letter from the disability insurance company stating that they are denying or stopping payment of your benefits.  

Once you receive a denial or termination of benefits letter, your options to appeal will depend on the type of disability plan you have. If you have a typical group disability benefits plan or an individual disability insurance policy, then you have the option to use the insurance company’s internal appeal process or you can immediately hire a disability lawyer to file a claim against the insurance company for the payment of the denied benefits.

The Internal Appeals Process – Should you do it?

All disability insurance policies and plans allow you to appeal a denial of your claim. Insurance companies have different procedures for these appeals, but typically they are completely unstructured, there are no procedural guidelines, and it simply involves having another person or so-called “committee” in the insurance company review your claim. You won’t be given much guidance on what to do for the appeal other than to send in any “new medical information”.

Disability insurance companies try to dress up the internal appeals process by calling it such things as an “impartial, thorough and objective” procedure – but in our experience – this is the furthest thing from true. The reality is that having an insurance company deciding an appeal of its own claim denial is like a fox guarding the hen-house. Often times, it does not matter what further or new medical condition is submitted to the insurance company – and the insurer, who technically is not a “medical investigator” will not request records from your specialists, treating hospitals, rehabilitation advisors, pharmacological printouts or anything much more than your family doctor. Most “new” medical information in support of your appeal will consist of a report by your family doctor and a letter written by you.

There are two problems with this typical approach to internal appeals.  First, simply asking your doctor to write another report, without giving him or her any guidance regarding your policy definition of a “total disability” is never really effective. Your doctor will more likely than not write a report outlining your conditions and why you cannot work – but what would be much more effective is if you or your doctor were better educated by the insurer and what is required to satisfy the definition of total disability as set out in your policy. This of course, never happens. Claimants are simply not properly guided or educated on what it means to be totally disabled by their insurer. In fact, 100% of the claimants that we end up seeing after a disability denial simply “get the denial letter” relating to their condition not meeting the definition of total disability within their disability policy. For many claimants, believe it or not, the first time that they hear the term “total disability” is when the door is being shut.

Second, the letters that we see claimants sending into their disability insurance companies in support of their appeals are often ineffective. Claimants are often living in times of stress and desperate need when they write their letters of appeal. Also, it is common for people to make threats that they will get a lawyer. While this may work when dealing with ordinary people, disability carriers will not be swayed by the threats of a lawyer.

Whether or not you should follow you disability insurer’s advice is ultimately up to you – but it’s important that you understand that most internal disability appeals are not successful – and even worse, for every month of “delayed response” by your disability claims insurer is a delayed payment to you. Disability lawyers often called them “detours” to the final destination – meaning that disability insurance companies will keep you on the detour of denials until your routes of appeal are exhausted, all while your benefits are not being paid…and delayed.

Hiring a Disability Lawyer instead of going through the Internal Appeal Process

The alternative to going through the internal appeal process is to hire a disability lawyer to help guide you through the claims process. By hiring a disability lawyer, you are not left wondering about the future and whether or not your internal appeal will be favorable or not. An experienced disability claims lawyer can start the claim for your long-term disability benefits immediately – and not only ensure that your disability insurance company has all of your updated clinical records – but can also ensure that the best specialists and experts are hired to support the fact that you are totally disabled as per your policy definition.

Another reason to hire a disability lawyer sooner rather than later is to protect your limitation date. In Ontario, you have two years to file suit against your disability carrier. The danger with internal appeals, delays and then more internal appeals is that process may well interfere with your limitation date – which begins with the unequivocal denial of your claim. It does not matter that claimants are invited to appeal the denial of their claims internally with their disability carriers – the limitation started from the date of your original denial letter.

Our Hamilton long-term disability lawyers have litigated against every major disability insurance company in the country. When you retain our disability law firm, we ensure that we take the time to investigate your entire medical history so that we can request every clinical note and record in existence in order to support your illness, disease or disability. We waste no time in filing a claim for your wrongfully denied long-term disability benefits so that in the end, things are not delayed unnecessarily for you and that, if successful, you are paid sooner rather than later. There is no waiting for an “internal appeals” decisions from another insurance company employee. There is the guarantee of knowing that if your benefits have been wrongfully denied, you have experienced disability lawyers in your comer, every step of the way.

  1. What is an “internal appeals process”?

    For a plan member or claimant who's claim has been denied, disability insurance companies often allow internal appeals – meaning that they allow their claimants to submit “additional medical information” to an internal disability appeals team or committee to review in support or approving their disability benefits.

  2. What are the chances of an internal appeal being successful?

    We often compare it to the “fox guarding the hen-house” – meaning that is is simply another disability insurance member or members that will be reviewing your appeal. In our experience, 99.9% of internal apepals fail.

  3. When should I contact a disability lawyer?

    We suggest that you contact a disability lawyer the moment that you are denied your disability benefits. Do not wait – the longer you wait – the longer you will wait for your reinstatement of benefits or a settlement of your claim.

  4. Is talking to a long-term disability lawyer free?

    Yes, our Ontario disability lawyers never charge for advice. We are simply happy to assist in explaining your legal rights to you.

  5. How do I pay a disability lawyer?

    The good news is that you don't. Our disability lawyers only get paid when you get paid – at the end of your claim. If we are not successful, we do not charge you a dime.

If you’ve been denied Long-Term Disability, contact our Ontario Disability Lawyers today.

If you’ve been denied long-term disability benefits, our Ontario disability lawyers can help answer any questions that you might have. We NEVER charge clients upfront and our consultations are 100% FREE. Contingency fee billing arrangements are the last type of payment arrangement lawyers will use in disability insurance cases. Contingency fee agreements are often referred to as no-win, no-fee agreements.

With these agreements, the payment of legal fees is one hundred percent conditional upon the lawyer being successful. In addition, with our contingency fee agreements, we take on the risk of payment for the expenses necessary to run the case. These expenses include things like paying for copies of medical records, court filing fees, paying for additional assessments and testing. Expenses on a disability case can easily be several thousand dollars and tens of thousands of dollars if your case goes to a trial. We would only get paid back for these expenses if we win your case. We always agree to take-on this additional risk – and if we don’t win, you don’t pay a thing.

Call us today no matter where you are in Ontario at 1-844-LALANDE or local in the Hamilton/Burlington/Niaraga areas at 905-333-8888. Alternatively, you can send us a confidential email and we will happy to get right back to you.


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