Sustaining a severe injury or developing a serious illness can significantly impact an individual’s ability to live an independent life. Both physical and mental conditions might prohibit individuals from enjoying the activities they usually engage in, and may even prevent them from earning a regular income. 

If an individual receives a medical diagnosis for a condition that prevents them from performing the duties of their job for a lengthy period of time, they may find themselves struggling to navigate a prolonged recovery period while worrying about how they’re going to pay their bills. These individuals may be eligible to receive some financial compensation in the form of long-term disability benefits

But even if you’re an insurance policyholder in good standing and believe your medical condition should entitle you to receive long-term disability benefits, insurance providers may deny your claim, or terminate your benefits payments after a period of time. If your claim for benefits has been unfairly denied or your payments have been ceased before you’ve recovered from your medical condition, a Nova Scotia disability benefits lawyer may be able to help you overturn the insurance company’s decision.

Understanding Long-Term Disability Benefits

In order to apply for benefits, you must be enrolled in an insurance policy that covers long-term disabilities, either through your employer’s group plan or your own private policy. You must also have been diagnosed with a medical condition that prohibits you from performing the duties of your job for an extended period of time.

Some examples of medical conditions that may qualify an individual for long-term disability benefits include:

  • Heart disease
  • Back problems
  • Chronic pain or complex regional pain syndrome (CRPS)
  • Lupus or Lyme disease
  • Psoriatic arthritis or fibromyalgia
  • Depression
  • Bipolar mood disorder
  • Post-traumatic stress disorder (PTSD)
  • And possibly more

Long-term disability benefits provide eligible policyholders with a percentage of their regular earnings while they’re unable to return to work. In Canada, long-term disability plans usually replace between 60-70% of a recipient’s normal income. Generally speaking, policyholders do not become eligible to collect long-term disability benefits payments until they have exhausted all other compensatory options available to them, such as paid sick leave, vacation time, and short-term disability benefits. 

If you do not qualify for long-term disability benefits through your insurance plan, but your medical condition prevents you from earning a living, you may be able to receive compensation from the Canada Pension Plan (CPP).

Since eligibility requirements for long-term disability benefits vary between insurance policies, it may be difficult to determine whether or not your disability qualifies you to receive payments. To apply for long-term disability benefits, you may need to submit medical records, testimonies from medical experts, and other documentation proving that your medical condition prevents you from performing the duties of your job. 

If you’re having trouble understanding the terms of your policy, or require assistance preparing a thorough and accurate claim for benefits, a disability lawyer may be able to review your policy and provide useful advice.

Reasons Long-Term Disability Benefits Claims May Be Denied

An insurance provider may deny your claim for long-term disability benefits for a number of reasons, even if you believe your condition qualifies you to receive them. Oftentimes, benefits claims in Nova Scotia are denied due missing records, insufficient medical documentation, skipped appointments with physicians, or other technicalities that may be resolved through an internal appeal to the company. 

However, the decision to deny certain claims may be the result of more complex determinations, which can sometimes be difficult to comprehend. An insurance provider may stipulate that the applicant’s medical condition does not fall under the company’s definition of a disability. Furthermore, based on the terms of individual insurance plans, if a claim for long-term disability benefits is related to a policyholder’s pre-existing condition (i.e. a medical diagnosis they received before enrolling in the insurance policy), they may be required to pay insurance premiums for a number of years before becoming eligible to collect benefits, or their claim may be denied altogether. 

Upon receiving notice that your claim has been denied, you should be provided with a letter from your insurance provider that includes the following information:

  • Details about your policy’s eligibility requirements for long-term disability benefits
  • The insurance company’s definition of “disability”
  • The reason your claim for benefits was denied
  • And possibly more

If you’re unsure why your claim was denied and believe your condition should qualify you to receive benefits payments, a disability benefits lawyer may be able to review your policy and your medical records to advise you on potential legal options that may be available to you.

Terminating Long-Term Disability Benefits Payments 

Even after eligible recipients begin collecting long-term disability payments, their benefits may be subject to term limits. Depending on individual policy stipulations, even if a benefits recipient’s injury, physical illness, or mental health condition continues to prevent them from performing their jobs, their payments may be discontinued once the set term limit has been reached. 

Insurance companies may also require policyholders who collect benefits to undergo frequent health assessments to monitor their recovery process. Based on these medical check-ups, if an insurance provider determines that a benefits recipient is physically able to return to work, they may stop providing their monthly benefits payments. Insurance companies may also monitor benefits recipients’ social media accounts in order to find evidence that their medical conditions no longer affect their ability to return to work.

According to the Nova Scotia Human Rights Commission, employers have a duty to accommodate employees with disabilities. As such, it is incumbent on them to go to reasonable lengths to help disabled staff members retain their employment, even if that means adjusting their work schedule, or their role within the organization. Once an employee who has sustained a debilitating medical condition has collected long-term disability benefits for two years, their insurance provider may reassess their eligibility based on their ability to perform the duties of other jobs. In these situations, if your insurance provider believes you are able to work in another capacity, even if it is unrelated to your current position, they may decide to terminate your benefits payments.

But the decision to terminate benefits payments based on an individual’s ability to perform any job is not influenced by the availability of another job at a policyholder’s workplace. If all of the organization’s available positions within the parameters of an employee’s ability are already filled by other staff members, keeping them on the payroll may create an undue hardship for the employer. In these cases, injured or ill individuals may find themselves with terminated long-term disability payments, and terminated employment.  

If your long-term disability payments were unfairly terminated, a disability benefits lawyer may be able to help you appeal the insurance company’s decision.

Filing an Appeal for Denied or Terminated Long-Term Disability Benefits Claims

Although an injury, physical illness, or serious mental condition may continue preventing employees from returning to the workforce after they’ve exhausted all their available options for financial compensation, they may find themselves navigating a long and complicated process when their claims for long-term disability benefits are unfairly denied or prematurely terminated.

In these circumstances, the assistance of a disability lawyer may allow an injured or ill insurance policyholder to focus on their recovery, while a legal advocate appeals the insurance company’s decision on their client’s behalf.

Based on the reason provided for a claim’s denial, a lawyer may advise their client to file an internal appeal directly through the insurance provider. In these cases, a lawyer may be able to help their client compile and submit crucial documentation, including assessments from medical experts, in an attempt to substantiate their claims and overturn an insurance company’s decision.

However, the internal appeals process can take an extremely long time, and may not be a fruitful course of action. Based on the legal advice from a disability benefits lawyer, a claimant may decide to file an external appeal, or a lawsuit, against the insurance company. If so, their eligibility to collect long-term disability benefits would be determined by an external arbitrator, and not the insurance company.

If the external appeal process is resolved in favour of the denied benefits claimant, they may be awarded payments for:

  • Previously denied benefits payments
  • Legal fees
  • Damages for mental stress experienced
  • Punitive damages
  • And possibly more

Call Preszler Injury Lawyers Today

If a severe medical condition such as an injury or illness prevents you from earning a living, and your claim for long-term disability benefits has been unfairly denied or prematurely terminated, Preszler Injury Lawyers may be able to provide useful legal advice and assistance. Following a review of your case, a Nova Scotia disability lawyer may be able to explain the legal options available to you, and, if eligible, appeal the insurance company’s decision on your behalf.

To review your case in a free, initial consultation, contact Preszler Injury Lawyers today or call us at 902-405-8282.