Articles Posted in Disability Claim

Long Term Disability cases are at their essence, contract cases.

In a long term disability case, there is a contract of insurance between the Plaintiff and the Defendant. The contract is between the Defendant insurance company (Great West Life, Canada Life, Manulife, Sun Life, Empire Life, Desjardins Insurance, SSQ Insurance, Co-Operators Insurance, RBC Insurance, La Capitale Insurance etc.) and the Plaintiff policy holder.

A car accident case for pain and suffering or a dog bite case is very different because there is no contract between the Plaintiff accident victim and the at fault party. These are straight tort cases. Accident benefit cases for first party insurance are certainly different, but the legal principal is the same given that the cause of action for tort cases is not contractural. In both car accident and dog bite cases the cause of action is in negligence against the at fault party.

The policy holder can be a company which covers all of its employees (a group policy through your employer), or it can be an individual policy of insurance.

In the case of an individual policy of insurance, the policy holder goes out and purchases the insurance on their own either directly through the insurance company, or through an insurance broker. The insurance broker may sell a variety of different policies underwritten by a variety of different companies. Variety is the spice of life, so getting options to purchase your insurance is a good thing. That way the consumer can compare and contrast prices, definitions, exclusions and benefits between polices. Having a good and knowledgable insurance broker is very helpful when comparing and contrasting long term disability policies.

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In Canada, we live in a free and democratic society. We are supposed to have access to the Courts when things go wrong in order to pursue justice and protect our rights and freedoms. When you’ve been wronged, and all else fails, you ought to be able to pursue your remedies before a Judge, in a Court of law.

This concept sounds great. But, the reality is, the idea of access to the Courts to protect our rights and freedoms simply does not exist (notwithstanding any delay in having your case heard, or lack of judicial resources; which is a topic for another day).

Want a few examples? Sure….

Innocent injured worker hurt badly on the job on account of the blatant negligence of their employer. Think you can sue? WRONG! Schedule 1 Employee vs. Schedule 1 employer can’t sue. That claim will likely be statute barred, and the injured worker will need to pursue matters through the WSIB. There are no large awards for pain and suffering (or large awards for that matter) at the WSIB. If you don’t like the result at the WSIB, you may apply for leave to appeal the result to the Court, but your case will NOT be heard by a jury of your peers, if it’s even heard at all.

Involved in a single car motor vehicle accident and your own car insurer is denying your accident benefit claims every step of the way? It would seem reasonable and only logical that the injured motorist can sue their own insurer for benefits denied. WRONG! Those sort of claims are now statute barred under the SABS and the Insurance Act. All disputes must go before the License Appeals Tribunal or LAT. The majority of those proceedings occur in writing, so the injured motorist doesn’t even get their “day in Court” so to say. If the injured motorist isn’t satisfied with the LAT’s decision, they can appeal to the Court, but again, their case won’t be heard by a jury of their peers.

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Last week’s Toronto Injury Lawyer Blog Post was entitled “Long Term Disability Claim Delay = No Pay (Ontario). If you didn’t check out that blog entry, you can do so here.

We got a lot of positive feedback from our readership which we have been permitted to share with you! We think these comments will provide some helpful insight in to the challenges which people face when making a claim for Long Term Disability Benefits. There is assurance knowing that “you’re not alone” when it comes to understanding how LTD claims work, how LTD policies work, how/why you’re getting denied; and how insurance works in general.

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Bills stack up. Particularly around the Holiday season. Unless you’re independently wealthy or have amassed considerable savings, you’re ability to pay off these bills comes through income generated from working (or very generous monetary gifts!). What could be worse than being unable to return to work on account of a disability; or losing your job because you can’t work.

Most LTD Policies pay a monthly benefit at rates of 80%, 70%, or 66% or your net pre-disability income. This leaves a significant shortfall; even if your LTD claim has been approved by the LTD insurer. If you’re lucky, you may have one of those few policies which pay out LTD benefits at a higher percentage. But, those policies are expensive and few and far between.

Many clients want to know how they can speed up the processing and response time of their LTD claim. How can they get approved faster; so that their debt burden is more manageable?

If our LTD lawyers knew the answer to these questions, we would share it with the world. Unfortunately, there is no science behind the speed at which your LTD claim will get approved or denied. A lot of it depends on the insurance adjuster on the other end; the nature of your disability; the culture of the insurance company you happen to be dealing with; along with the amount of medical records involved in your LTD claim. The fewer records which an insurer has to review, the less time it ought to take to deliver a decision on your claim.

But, we see a number of instances where the LTD insurer requests more and more records. One set is just never enough for them to make a decision; one way or another. Some see this approach as thorough; and the LTD insurer is just doing their job. Others see it as frustrating; and an effort by the insurer to latch on to a document to deny a meritorious claim.

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Long Term Disability Insurance, and Critical Illness insurance are both “living policies“. They differ from a death benefit or life insurance policy in that the insured is still alive and the beneficiary; while alive; is able to recover the benefits.

In a “death policy” or “non living policy” only the designated living beneficiary, trust or corporation can recover the benefit. Somebody will need to have died in order to make a claim or recover benefits.

When making a claim for long term disability or critical illness benefits, it’s important to know what you’re getting in for.

Those application forms and questionnaires are very important. They are source documents for your case. They will go on to provide evidence upon which an insurer will use to potentially defeat your claim. These forms will also be scrutinized by a Judge or Jury with respect to how they were completed, what they say, and even when they where filled out.

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A lot of our practice is focused on litigating short term, and long term disability claims against large insurance companies such as Manulife, Great West Life, Sun Life, Industrial Alliance, RBC Insurance, La Capitale Insurance, Co-Operators Insurance, Equitable Life, Canada Life etc.

These claims arise when a policy holder, of disability claimant; makes a claim on their Long Term Disability Policy (LTD), but their claim gets denied by the insurer. When that happens, people call our law firm and we’re able to help them get the benefits and justice which they deserve.

The area of Long Term Disability Law can be very confusing. Unlike a car accident, slip and fall or dog bite claim where we are able to clearly identify the wrong doing or negligence, a Long Term Disability Claim is purely contractual. That means if you don’t have an LTD policy, then you can’t have an LTD claim. It’s that simple.

The parameters of the claim are set up by the wording of the policy. Because every LTD policy is unique, every claim is very different.

Here’s a quick example. Some LTD Policies provide for benefits at 65% of your gross monthly earnings. Other policies provide for benefits at 75% of your net monthly earnings. Some policies provide for LTD benefits up to the age of 65 years old. Other policies provide for LTD benefits for just 5 years. The definitions of disability in each policy is also different and can vary dramatically from policy to policy. Some policies contain onerous exclusions for disability if based on a soft tissue injury or psychological illness. Other policies don’t contain those sort of exclusions.

The level and amount of coverage all depends on the policy, and how good (or bad) it is for the claimant. The claimant didn’t draft the policy. They were drafted by insurers, for the benefit of insurers to limit their potential exposure.

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Our law firm handles a wide array of personal injury and disability claims. Many of our cases are against large, multi-national insurance companies who provide all types of insurance coverage. One of the most common sort of claims we see are Short Term, and Long Term Disability claims against such companies as SunLife, Manulife, Great West Life, Industrial Alliance, Canada Life, Co-Operators, RBC Insurance, Desjardins, SSQ etc.

One of the biggest eye openers for our clients is what happens when they take a look at the fine print contained in their respective long term disability policies. After all nobody other than a personal injury lawyer uses an LTD Policy as their night time reading material.

These LTD policies are written by insurers, to minimize the potential exposure of an insurer; while giving the appearance that you’re getting amazing coverage. For most group and individual policies, you get what you pay for. The cheaper the policy, the cheaper the coverage. But even the best, and most iron clad policies are riddled with loop holes which may minimize your potential claim.

The purpose of this week’s edition of the Toronto Injury Lawyer Blog Post is to examine your run of the mill LTD Policy, and examine those provisions therein designed to limit your claim.

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Our law firm litigates countless Long Term Disability (LTD) claims against large, multi-national insurers such as Great West Life, Sun Life, Manulife, Industrial Alliance, Desjardins, SSQ, Canada Life, Empire Life, RBC Insurance, Co-Operators, Equitable Life and the list goes on.

Litigating these claims can prove to be difficult for a variety of reasons.

It’s important for all claimants to understand that these claims are based on what the policy says. In our office, we refer to this concept as the four corners of the insurance policy.

There are certainly ways around these four corners, along with way at tackling damages for LTD claims which are outside of the scope of the police such as punitive, aggravated and damages for mental distress. But these topic will not be covered in this edition of the Toronto Injury Lawyer Blog Post.

For now, we are going to focus on damages under the LTD policy.

The policy will define what the monthly LTD benefit amount is; how long benefits will be paid for; when those benefits will begin to be paid; what medico/legal definition a Plaintiff must meet in order to be considered disabled under the policy; what injuries are and aren’t covered under the policy; and what exclusions would limit recover under the policy.

Plaintiffs/Claimants don’t write their policy. Insurance companies do. Accordingly; many provisions contained in long term disability policies aren’t there to protect claimants. Rather, they are there to protect the insurer’s interests so as to mitigate their damages and minimize any potential pay out.

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