What the Insurance Companies Don’t Tell You and How You Can Be a Savvy Policy Holder
Disability insurance companies are notorious for denying coverage for reasons that seem unfair. If you have an illness or injury that prevents you from making a living, you should be able to rely on disability insurance benefits.
“Insurance companies do not tell you that their job is to look for any and every way to not pay benefits,” said Samantha Share, Assistant Managing Director at Share Lawyers. Unfortunately, often claimants will not challenge a disability insurance denial because they are intimidated and believe that the little guy has no chance of winning against a disability insurance giant.
However, armed with the right information and preparation you can successfully challenge disability claim denials. Here are the primary reasons why disability claims are denied in Ontario, and why you should dispute them.
Inadequate Medical Evidence
The insurance company claims the diagnostic documentation or the doctor’s evaluation of your inability to work is not persuasive enough. This is a common stalling tactic. Share said, “Insurance companies can use tactics such as referral to an independent medical evaluation or rehabilitation services to gather more information in order to delay paying benefits.”
If you’re given this reason, consider calling a disability lawyer or use this free online tool to determine how an experienced disability lawyer can help because challenging a denied disability claim balances the playing field.
Pre-Existing Exclusion Clause
Under Ontario legislation, an insurance company is protected from having to provide benefits to individuals who would have never been insured had the medical condition been previously disclosed. However, these clauses are often open to interpretation and an experienced disability lawyer may be able to determine that the insurer’s timeline analysis is not valid or that the claim is based on a new medical condition that would not be caught by the pre-existing exclusion clause.
Determination of “Total Disability”
If your illness or injury prevents you from performing the main duties of your “own occupation”, you may qualify for disability benefits. After 12-24 months, a medical consultant will determine if you can transition into “any occupation” coverage. Often insurance companies will say that while they accept that you cannot do your own job, that you should be able to do something, which leads you to believe you need to be suffering a catastrophic illness or injury. But this is the furthest thing from the truth. To consider whether you can overcome this termination of disability benefits you should consult an experienced disability lawyer.
You’re Under Surveillance
Often insurance companies will use private investigators to follow people in their everyday lives. The whole idea of being tailed by a stranger who is hunting for a “gotcha” moment can be distressing. Unless you’re lying about your injury or illness, there is nothing to worry about.
Their Medical Expert Contradicts Your Doctor
Their medical doctor doesn’t think you’re disabled. Who will a judge believe, an insurance consultant who has undertaken a brief assessment of your condition, or your own doctor who has cared for you for years? Share said, “They often will refer to an in-house medical consultant on which to base their decision not to pay benefits.”
What is Your Next Step?
Claimants who have been denied disability benefits should use one of the free online tools available to find out if they have a valid disability case and not wait to call a disability lawyer. The longer they wait, the longer they will be without income. Samantha Share said, “A disability lawyer can get the appeal or lawsuit process started right away. They also can make suggestions as to alternate forms of income that may be available to the claimant during the waiting period.”