Employment Terminated
In this successful appeal of denied Long Term Disability claim, a 60-year old female had a long history of depression and anxiety, which ailments were well controlled with anti-depressants and psychotherapy for many years. She held a steady desk job for over 10 years, working for the same company. However, her disease eventually progressed to such a degree that she was unable to handle her essential work duties any longer. She stopped working completely due to the debilitating symptoms caused by what was diagnosed by her treating doctors as Major Depressive Disorder, Generalized Anxiety Disorder, and Social Anxiety Disorder. Her employment was subsequently terminated.
Applied for Disability
As the client had access to group insurance benefits through her employment, she submitted an application for the benefits to the LTD insurer. Attending Physician Statement, in support of her LTD application, was completed by her treating doctor. The claim was initially denied due to insufficient medical evidence in support of disability. Upon receipt of the records from the family doctor and treating specialist, the LTD insurer accepted the claim and started paying the benefits.
Required Participation
After a few months of paying the benefits, the LTD insurer requested participation in a 10-session cognitive work hardening program, which they organized and funded. The client refused, questioning the reasonableness of the proposed program as she was being treated by a specialist already. The LTD insurer terminated the benefits relying on the rehabilitation provision in the Policy, which stated that “if a person does not participate or cooperate in a rehabilitation plan or program that has been recommended or approved by the insurer, she/he will no longer be entitled to benefits”.
In response, the client sought her treating doctor’s view in regards to the proposed rehabilitation program. Her doctor opined that it might be beneficial, and the client agreed to commence the program. The LTD insurer reinstated the benefits. However, after completing 3 out of 10 sessions, the client experienced a drastic deterioration in her psychological symptoms. She stopped attending and asked the LTD insurer to suspend the treatments. The LTD insurer responded by immediately terminating the benefits due to non-compliance with a mandatory rehabilitation program. The client appealed.
The Appeal
In her appeal, the client explained why she stopped participating in the rehabilitation program and, more importantly, provided a medical opinion from her treating doctor supporting her decision. While initial correspondence from the treating doctor was deemed insufficient by the LTD insurer, and the denial was maintained, a more comprehensive report resulted in a positive outcome. The treating doctor stated that it was his opinion that the work hardening program needed to be postponed due to the client’s worsening mental health. The LTD insurer accepted the treating doctor’s opinion, suspended the rehabilitation program (with a possibility of re-opening it at a later date), and reinstated the benefits.
A Positive Outcome
The LTD insurer was within its rights under the Policy to deny the benefits based on non-participation in the mandatory rehabilitation program. The client was able to succeed in her appeal by procuring a supportive opinion from her treating specialist justifying her request to suspend the program. Without such compelling medical evidence, the LTD insurer would have likely maintained the denial.
