Long-Term Disability Claims

Why was your claim denied?

Insurers use a predictable set of reasons to deny long-term disability claims. The most common justification is a lack of “objective medical evidence.” They will argue that conditions like chronic pain, depression, anxiety, or fibromyalgia cannot be proven by an x-ray or a blood test, and therefore do not meet the threshold for disability.

This is a legal fiction. Ontario courts have repeatedly ruled that subjective conditions are real, debilitating, and fully compensable under standard LTD policies.

Insurers will also deny claims by arguing that you are not receiving “appropriate medical treatment,” or by finding a minor discrepancy in your medical records and using it to challenge your credibility. Our job is to dismantle these arguments using specialized medical evidence and established case law.

The internal appeal trap

When an insurer denies your claim, their letter will almost always invite you to use their “internal appeal” process. We strongly advise against doing this without legal representation.

Internal appeals are rarely successful. They are evaluated by the same company that just denied you, using the same criteria. More importantly, the internal appeal process is often used as a stalling tactic to run out the clock on your limitation period, or as a fishing expedition to gather more information to use against you.

Commencing a formal legal action is often the most effective way to force an insurer to take your claim seriously. Once a lawsuit is filed, your file is transferred from an adjuster to a litigation lawyer, which fundamentally changes the dynamic of the negotiation.

The “Own Occupation” vs. “Any Occupation” shift

Almost all long-term disability policies in Ontario contain a critical shift at the two-year mark.

For the first two years (24 months) of disability, you are entitled to benefits if you cannot perform the essential duties of your own occupation. After two years, the definition of disability becomes much stricter. You must prove that you are entirely prevented from engaging in any occupation for which you are reasonably suited by education, training, or experience.

Insurers routinely use this transition as an excuse to cut off benefits, arguing that while you can’t do your old job, you could theoretically work a desk job or a minimum-wage position. We fight these “change of definition” terminations by proving that your limitations prevent you from maintaining any gainful, competitive employment in the real world.

CPP Disability and your LTD claim

Your insurer will likely require you to apply for Canada Pension Plan Disability (CPPD) benefits. This is because standard LTD policies allow the insurer to deduct any CPPD payments you receive from the amount they owe you.

If you are approved for CPPD, your insurance company gets a dollar-for-dollar credit. However, a CPPD approval is also a powerful piece of evidence in your favor. It means the federal government has recognized your disability as “severe and prolonged.”

We use CPPD approvals as leverage to force insurers to reinstate benefits or negotiate a fair lump-sum settlement. If you have been denied CPPD, we can also advise you on the appeal process and how it intersects with your LTD claim.

Speak with a long-term disability lawyer in Hamilton or St. Catharines

Cook Reynolds LLP represents clients with denied or terminated LTD claims across Hamilton, Burlington, St. Catharines, Niagara, Brantford, and the surrounding Golden Horseshoe region. Our initial consultation is free, and there are no legal fees unless we win your case.

For more detail on what to bring to your first meeting with us, read The Initial Lawyer Consultation: What to Bring With You.