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How Does an Individual Qualify for Long-Term Disability Benefits?

If a serious medical diagnosis prohibits an individual from working for a substantial period of time, they may be eligible to collect long-term disability benefits.

When injuries or illnesses prevent individuals from returning to their workplaces, they may exhaust the compensatory benefits available to them, such as paid sick leave, vacation time, short-term disability benefits, and even EI benefits. Once those available benefits have expired, if their medical condition still prevents them from performing the duties of their job, these individuals may qualify to receive long-term disability benefits. In Canada, long-term disability plans usually replace between 60-70% of a recipient’s regular wages.

In order to qualify for long-term disability benefits, claimants must be enrolled in an insurance policy that covers long-term disabilities, either through their employer’s group plan, or a privately held policy. If eligible, individuals whose medical conditions prevent them from working may also be able to receive compensation from the Canada Pension Plan(CPP).

To submit an application, claimants may be required to provide thorough medical evidence proving their medical conditions prevents them from working. However, eligibility requirements for long-term disability benefits vary between insurance policies.

When detailing the terms and conditions of their available coverage, insurance policies may use language that is difficult to understand. If you are unsure if your illness or injury qualifies you to receive long-term disability benefits, a Nova Scotia long-term disability lawyer may be able to review your insurance plan and help explain its eligibility requirements.

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Physical Injuries or Illnesses That May Qualify for Long-Term Disability Benefits

Many insurance policies stipulate that, in order to receive long-term disability benefits, a policyholder’s condition must prevent them from performing activities related to their current job. During this initial two year period, often referred to as the “own occupation” stage, employees may be eligible for long-term disability benefits if their illness or injury prohibits them from performing duties related to their specific job.

Usually, after this two year period has expired, an insurance policy’s eligibility requirements change. The eligibility requirements change from an inability to do your own job as a result of the medical condition to a more onerous definition of a recipient’s medical condition must prohibit them from completing the tasks of any job, even if it is unrelated to their current position.

Whether or not an individual’s physical illness or injury will entitle them to long-term disability benefits depends on the terms of their individual policy, and the physical demands of their occupation. Some physical conditions that may qualify individuals to collect 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
  • Paralysis
  • And possibly more

Pursuing Long-Term Disability Benefits for Mental Conditions

While physical injuries or illnesses can often be easily quantified by medical evidence, like the results of an examination, mental illnesses can be difficult to objectively assess. However, that doesn’t make severe mental health conditions any less debilitating.

Individuals suffering from serious mental conditions that prevent them from working may also be entitled to receive long-term disability benefits. Approximately 30% of Canadian disability claims are attributed to mental health conditions. Some examples of mental health conditions that may entitle an individual to collect long-term disability benefits include:

  • Depression
  • Bipolar mood disorder
  • Post-traumatic stress disorder (PTSD)
  • And possibly more

Often referred to as “invisible” illnesses, mental health conditions don’t necessarily manifest themselves in quantifiable, physical symptoms. That being the case, individuals pursuing long-term disability benefits for mental illnesses may face extra scrutiny from their insurance providers. Insurers may claim that they are unable to substantiate an applicant’s subjective emotional experience, even if the claimant supplied medical evidence proving that they’ve been receiving ongoing, necessary treatment for their condition. As a result, many benefits claims for disabilities related to mental health are often denied.

Filing a Long-Term Disability Claim

If you are an insurance policyholder in good standing, and have been diagnosed with an illness or injury that prevents you from completing the tasks required of your position at work, you may qualify for long-term disability benefits.

To submit a successful application for benefits, you may be required to include supporting medical evidence to support your claim. Your application’s approval may depend on a number of factors, including:

  • How, when, and where your illness or injury occurred or began
  • How your symptoms affect your ability to work
  • When you were last able to work
  • When your medical treatment began, and if it is ongoing
  • Your occupational duties
  • Your prognosis
  • And possibly more

Even if you prove that your medical condition prohibits you from carrying out the duties of your job, and you’ve supplied your insurance provider with thorough medical evidence to support your claim, for a number of reasons, your application for long-term disability benefits may be denied.

If your long-term disability claim was denied, but you believe your medical diagnosis should entitle you to receive benefits payments, a Nova Scotia long-term disability lawyer may be able to help you appeal the insurance provider’s decision.

What To Do if Your Claim for Long-Term Disability Benefits Was Denied

With the assistance of a long-term disability lawyer, Nova Scotians whose benefits applications were rejected may be able to appeal the insurance company’s decision. Depending on the situation, a lawyer may suggest filing either an internal or external appeal, or proceed with both courses of action, based on the reason provided for the claim’s denial.

In cases where insurance companies cite insufficient medical evidence as the reason for rejecting an individual’s benefits claim, a lawyer may advise their client to file an internal appeal directly through their insurer. To file this internal appeal, a lawyer may be able to help their client compile important medical documentation, including examination results and assessments from experts. By providing additional information, a lawyer appealing a denied claim may be able to help overturn an insurance company’s initial decision.

However, the process of completing an internal appeal can be difficult, and could take a significant amount of time. Denied claimants whose conditions prevent them from working, and therefore cannot earn a living, may not be able to spend months waiting for their insurance provider to review their appeal. Additionally, after a lengthy review process, the internal appeals process may not even change the insurer’s initial decision.

Claimants working with a long-term disability lawyer may, therefore, decide to file a lawsuit, against the insurance company. In these cases, whether or not an applicant’s medical condition qualifies them to collect long-term disability benefits would be determined by an external arbitrator, and not the insurance company.

If successful, qualified benefits recipients 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 physical illness, injury, or serious mental health condition prohibits you from working for a lengthy period of time, you may be eligible to receive long-term disability benefits. If you’re unsure whether or not your condition qualifies you to collect benefits payments, Preszler Injury Lawyers may be able to review your policy and explain the options that may be available to you. If your claim for long-term disability benefits has been unfairly denied, Preszler Disability Lawyersmay be able to help you appeal the insurance company’s decision.

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Schedule a call with our personal injury legal intake team. Our team is available 24/7 so call us now to book your call. Our scheduled intake allows you to tell us details about your accident and gives our legal team an opportunity to review your case and advise you on possible solutions and outcomes. The best part is, if you decide to hire us after this call - you don't pay anything unless we win. We can help clients regardless of where they reside in Nova Scotia & New Brunswick so let us help you get started on your road to recovery.


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