Area of Law: Personal Injury
Answer # 492
Making a long-term disability claimRegion: Ontario Answer # 492
If you have a long-term disability (LTD) that prevents you from working, and you are insured you are entitled to make a claim for benefits. To receive LTD benefits you must file a claim form as well as other documents and reports.
1. Obtain a claim form
- If you have private insurance provided by your employer as part of a workplace group disability plan, your employer will provide you with the claim form and instructions. Information about the types of coverage you have will be in your copy of the insurance policy or your employee benefits booklet.
- If you have your own private, individual disability insurance policy, you can obtain a claim form from your insurance company or your insurance broker.
- If you do not have private disability insurance, but you are covered by Workplace Safety and Insurance, refer to topic #635 How to apply for workplace safety and insurance benefits.
2. Get support from your doctor
To be approved for LTD benefits you must first prove that you have a disability. You must obtain documents and medical records from your health care providers that prove you have a physical or mental condition that makes you unable to work.
A health care provider can include many professionals, such as:
- medical doctor
- medical specialist
Your health care provider will usually:
- complete a medical certificate in support of your LTD application
- make recommendations to improve your symptoms and your ability to work
3. Complete the application
The application will consist of a number of different forms which are specific to your insurance company. However, they generally include the following:
Plan Member Statement
This form (also known as a claimant’s statement or employee application form) asks for details about the circumstances of your claim as well as authorization for the insurance company to communicate directly with your health care providers, and/or legal representative.
Your claim form will ask you a number of questions, which may include:
- How does your injury or illness prevent you from working?
- What specific duties can you perform and what duties are you unable to do?
- Is your disability a work-related illness, injury or accident?
- Have you had the same, or a similar illness or injury in the past?
- On what date did your illness or injury first prevent you from working?
- On what date did your symptoms first appear?
- Are you currently undergoing any treatment?
- What are the names of any physicians, specialists or any other medical professionals you have consulted?
- When do you think you will be able to go back to work at either your original job or another type of job?
- Are you receiving any other disability income (e.g. workers compensation benefits or CPP disability benefits)?
Attending Physician’s Statement
This document is completed by your medical doctor, or other medical professional. It should include test results, consultation reports, and any other relevant documents or reports which help prove your claim. You may have to pay a fee to your doctor to complete this form and for copies of the reports.
Plan Sponsor Statement
This form (sometimes called an employer application form) is completed and signed by your employer and must be sent directly to the insurer by the employer.
This form asks for a description of the major duties and responsibilities of your job, as well as any physical requirements of the job. It should be signed by both you and your employer.
4. Submit the application
The application form along with the other documents and reports that are required by your policy must be submitted to your insurance company. Depending on the insurance provider, you can mail, email or fax your application form and other information. The insurance provider will provide complete instructions about where and how to submit the application.
Time limitations for submitting your application
There are usually time limitations or deadlines for submitting your claim application. Confirm with your insurance company, or a personal injury or disability insurance lawyer what these deadlines are so you do not jeopardize your chances of the insurance company approving your claim because you missed a deadline.
5. Assessment of your claim
After you have submitted your application, the insurance company will assign a case manager, also called a claim representative or adjudicator, to review your application and make an assessment.
During your assessment, usually done by telephone or a home visit, your case manager will interview you and evaluate the following information:
- the medical information provided
- how your condition impacts your ability to perform your job
- your occupational demands
- your ability to complete daily living activities
The case manager may also:
- contact your health care providers
- contact your employer
- ask you to take an independent medical exam or evaluation arranged and paid for by the insurance company
It normally takes between 7 to 30 days for the assessment to be completed and the application for LTD benefits to be decided.
What happens if your claim is approved?
If the insurance company approves your claim both you and your employer will be notified in writing. The notice will include how long you will receive benefits for and the amount. Benefits are usually paid monthly. For more information, refer to topic #495 How much do long-term disability benefits pay and for how long?
What happens if your claim is denied?
If your claim for LTD is denied you will receive notification in writing, which will usually include the reason you were denied. The insurance company will offer you the opportunity to appeal the decision. You may also be able to file a lawsuit against the insurance company, your insurance broker, or your employer, depending on the circumstances. For more information, view #493 What to do if your claim is denied.
Get legal advice and help
Filing a claim for LTD can be a difficult, confusing and lengthy process. Each policy is different. Submitting an incomplete or inaccurate application can lead to a claim being denied. A personal injury or disability insurance lawyer can help you understand your policy, notify you of any deadlines, guide you through the claim process, review your forms and documents and deal with the insurance company. This will help ensure that you will get the benefits you deserve in a timely manner.
Even when an individual has a legitimate cause for claiming their long-term disability benefits, often insurance companies will initially deny the claim, or offer an amount much lower than asked for.
If you or someone you care about suffers from a long-term disability and has disability insurance, contact our preferred experts, Nicola (Nick) Giannantonio Legal Services . They can help you get the LTD benefits you are entitled to, even if your claim was denied. They offer a free consultation and do not charge up-front fees.
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