How Unclear Medical Records Can Lead To Denied Disability in Ontario

Accurate Medical Records Help With Claim Success

If you keep accurate, detailed medical records, you’ll have a much easier time if you ever need to file a disability claim. That’s because both government and private insurance programs mandate that all medical conditions be meticulously documented before any disability claims get paid and can be the major contributor to denied disability claims in Ontario.

This guideline applies not just to Canada Pension Plan (CPP) claims but to employer-funded and private insurance plans as well. In the insurance industry, particularly the medical/disability sector, documentation is of paramount importance.

When you don’t have sufficiently detailed records, or when you have no records at all, insurers have no way of knowing whether your claim is legitimate. What’s the definition of “good medical records,” and why are claims sometimes denied by private and government insurers, like the CPP?

Additionally, how can a lawyer help you if you need clarification on these questions or wish to get help if you were previously denied disability in Ontario?

Why Good Medical Records are a Must

Good medical records consist of timely, accurate, complete documents that honestly and clearly state when and what you were treated for, by whom you were treated, why you were treated, and what the outcome was.

These seven components of “accurate medical records” are the minimum criteria to meet the definition, namely:

• Timeliness: the records should be created at the time the treatment is given, not later
• Accuracy: documentation should contain only those medical services that were performed
• Completeness: records should be detailed enough so as to offer a full, understandable picture of what was done
• Date of service: the actual dates that medical services were provided to you.
• Reason for treatment: within the medical record, there should be a statement by the professional care provider explaining why you sought treatment
• Provider: the name, address, credentials, and contact information of the medical provider
• Outcome: what happened as a result of the treatment you sought and received

Why Claims are Denied

If you have been denied disability in Ontario for a private or CPP claim, the insurer will inform you of the reason for the denial. In many cases, denials are a direct result of inadequate medical records. In addition to private disability insurance coverage, Canada has had an official government program, called the Canada Pension Plan, since 1965. But for CPP and all private or employer-based insurers, the rules about medical records are regularly updated. New requirements are added regularly. That’s why it’s imperative to always maintain your own records in as detailed a manner as possible.

Why are claims denied by private, employer, and government insurers? Here are some of the most common reasons:

• You’re under the age of 65: For CPP disability payments, you must be 65 or older to file a valid claim.
• You haven’t contributed enough: You need to have worked long enough to contribute a minimum amount into the CPP plan.
• Your disability must be classified as both “prolonged” and “severe” for CPP claims. This is the part of CPP claims where applicants are often
• denied due to insufficient medical records.
• Your condition does not meet the definition of “disability” according to your private insurance policy.
• Your condition is not covered by your privacy policy.
• The private insurer denies the claim due to inadequate medical records.

Getting Legal Help

Keeping accurate, legally sufficient medical records is a challenging task. On top of that, you need to know how and when to file a successful claim. Especially if you have been denied disability in Ontario, it’s important to hire a lawyer to resubmit a claim. Yes, many people “go it alone” and attempt to try again and again when their first, second, or third attempts to get disability are turned down. Hiring a competent lawyer who has experience with CPP and private disability claims is a much wiser approach and improves your chances for success.

Even before calling a lawyer, it can be helpful to study the official CPP website where all the rules are listed pertaining to how to file and what kinds of documentation you need to make a successful claim.