What Steps Do I Take If My Insurance Company Denies My Disability Claim?
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      Disability

      What Steps Do I Take If My Insurance Company Denies My Disability Claim?

      What Steps Do I Take If My Insurance Company Denies My Disability Claim?

      When your insurance company decides to deny your disability claim (and this might happen at the outset of your claim or after the insurer pays you short-term or long-term disability benefits for some time), they notify you of their denial in writing. You should review their denial letter carefully. Look for the basis for a denied disability claim.

      Sometimes, the basis for the denied disability claim is some straightforward non-compliance or deficiency that you can try to quickly resolve. For example, the insurer might claim that they cannot properly assess your disability claim because your doctor has not sent them the records. You, of course, can try to assist by contacting your doctor. If the basis for the denied disability claim is that you are not complying with some recommended treatment, you can agree to attend the treatment as long as it looks reasonable and necessary for your disability.

      If, however, the denial letter explains that your disability claim has been denied because your disability has not passed the disability test, such denial turns into a dispute that you need to appeal and likely contest in the court. Your appeal rights are normally explained in the insurer’s denial letter. You are to submit your appeal to the same insurance company that denied your disability claim in the first place.  If your denial letter states a pre-existing condition – you may have a case if you can meet the pre-existing requirements of your policy.  You may need help sussing out those allowances and limitations.

      In your appeal letter to the insurer, you are expected to explain why the insurer’s denial should be reversed and why your denied disability claim should be allowed. You may attach any medical or other records that are favorable to your disability claim and that the insurance company does not yet have. Some insurance policies allow for several such appeals. Most insurance policies set out a deadline for submitting an appeal. So, look closely at the insurer’s denial letter but also at the actual insurance policy in order to learn about important deadlines and about your appeal rights in general. If you cannot get clear answers, it would be advisable to contact a disability lawyer for help.

      If your appeal does work, the insurer will start or resume paying short-term or long-term disability benefits to you. This does not prevent the insurer from denying your short-term or long-term disability claim some time down the road. They can (and probably will) deny your disability claim again and again. At that point, depending on the basis for their new denial, you can decide to appeal their denial again.

      If your appeal does not work (a more common scenario), and the insurer keeps claiming that you are not qualified for short-term or long-term disability benefits under the disability test, your only recourse is to sue the insurance company in court. It would be prudent to contact a disability lawyer to assist you in this process. Do not delay your decision. In Ontario, your right to sue is subject to a limitation period, which, in simple terms and with several exceptions, gives you only 2 years from the date of the denial of your disability claim to issue a lawsuit. If you fail to sue within the limitation period, you may lose your right to sue forever. And some disability insurance policies actually reduce the limitation period to 1 year from the date of the disability denial. Again, it is important that you review the denial letter and your insurance policy for any important deadlines or, better yet, contact a disability lawyer to ensure that all your rights are preserved and protected.

      Disclaimer: The content of this article is a general guideline made available for educational purposes only and is not intended to be used as legal advice for the reader's specific situation nor in general. By reading our blog and website content, the reader acknowledges the above and understands there is no lawyer-client relationship created between you and Himelfarb Proszanski through this content. To get specific legal advice, we encourage you to book a free consultation with one of our lawyers to clarify the legal aspects of your situation.