How do Insurance Companies See Claims for Long Term Disability (LTD) Benefits?
The disability insurance company is not your friend. We cannot stress this fact enough. Over the past 35 years our disability lawyers have seen it all, and we want you to be protected by knowing what to expect.
Disability insurance companies are very friendly with people paying premiums. And they extend wonderful invitations through media and advertising for you to come under their protection so that you can feel financially secure in the event that you become unable to work due to a long term disability.
Canadian disability insurance companies often treat claimants very differently. You may be one of the lucky ones – and we hope so. A certain percentage of cases are handled perfectly and approved quickly. But an alarming percentage of valid claims are denied - recent numbers estimate that 60% of long term disability claims are denied. It’s very difficult for many people who have faithfully paid their premiums to believe this.
Roles Within the Company That Will Impact Your LTD Claim
Within an insurance company there are several departments, including underwriting and claims that are involved in long term disability benefit claims.
An underwriter decides whether applications for insurance coverage (risks) should be accepted and on what terms. In the disability insurance market, an underwriter assesses risk according to the likelihood of an employee becoming disabled and assigns a dollar value to that risk in the form of an insurance premium. That premium is calculated by weighing a number of factors and asking for detailed information from prospective clients (employers). These companies operate under the assumption that premium dollars paid by its insured, or “policyholders,” and the return on its investments from those premium dollars will be greater than claims incurred (money paid out) and expenses.
If you have filed a disability claim, you will most likely be familiar with your claims adjuster, sometimes referred to as a claims analyst. A claims adjuster generally determines the extent and validity of claims. He or she assesses liability and negotiates any payments paid out. Claims adjusters are responsible for managing and controlling claims costs.
They manage the process of dealing with a claim when it is first made and follow it through. Thus, the claims adjuster is normally the representative at the insurance company with whom the individual filing a disability claim is most familiar.
Why Insurance Companies Deny So Many Long Term Disability Claims
The insurer has two teams – offence and defence. When they are on the offence they are making promises and getting more policyholders. The more policyholders they have, the more money they take in. With this side of the business, they are friendly and reassuring. The other face comes out when someone asks them to honour a disability claim.
These companies look at your claim with the attitude that you are probably lying to them. The claims adjuster plays defence for the insurer. It is the adjuster’s job to help minimize and restrict the amount of money that goes out to claimants.
Claims adjusters have not generally received extensive education in claims handling. They receive on-the-job training on how to evaluate a claim and the grounds for saying no. Saying no is the desired response. They are not issued written guidelines for turning down claims. They are provided with guidelines regarding medical conditions and the accepted duration of disability from a particular injury or illness. Often such guidelines are treated as being black and white without any reference to the specific considerations that impact your specific reasons for not being able to work.
After receiving your claim, your adjuster will typically require more information from you. After they get it, they will probably ask for more. It is not unusual for you to have to send the same information a few times before they acknowledge receipt. These are the games you may find yourself reluctantly playing while trying to secure your benefits. We don’t have to tell you that this is an outrageous way to treat someone managing a disabling medical condition. Try to maintain an even keel in all your conversations and correspondence with your insurer.
Common Reasons for Long Term Disability Benefit Denials
Insufficient medical information: This is a very common response when applying for your disability benefits. It’s their way of saying that they don’t feel there is enough medical proof to support you being on disability leave. We believe that decision should be made by your doctors, as they are the ones who understand your medical situation best. If your claim has been denied because of insufficient medical evidence, we can help.
Do not meet the definition of disability: This is another common reason that a claim gets denied. They feel you are not disabled enough and are capable of doing your job. They are overriding your doctor’s opinion and forming their own views on your medical situation. This is not right. If your doctor is supporting your disability leave, then they should be supporting you as well. If they are not willing to, then we can help.
They believe you can work: They might have you speak to one of their doctors or have their doctor review your medical claim. While they may base their decision on the opinions of their doctors, the opinions of your doctors (and other health care providers) are important as well - they have your best interests in mind and know you better than a doctor who has spent a very limited amount of time assessing your disability. If their doctor’s review has resulted in a denial of disability benefits, then you need to contact us immediately.
Their doctors believe you can work: They might have you speak to one of their doctors or have their doctor review your medical claim. While they may base their decision on the opinions of their doctors, the opinions of your doctors and other health care providers are important as they have your best interests in mind and know you better than a doctor who may have only reviewed a paper file or spent a very limited amount of time assessing your disability. If their doctor’s review has resulted in a denial of disability benefits, then you need to contact us immediately.
Pre-existing medical condition: If your insurance company denies your disability claim stating that your medical condition is pre-existing and you have already received medical attention for this condition, they may not be disputing whether you are disabled, but rather stating that the medical issue that is causing you to stop working existed prior to your disability insurance coverage came into effect.
A pre-existing exclusion under your policy only applies if you have been covered under the policy for a limited period of time (commonly in the first year you have benefits in place). This kind of denial requires a proper review of your medical records to determine if they were right to have denied you. It’s best to speak to one of our long term disability lawyers to see if it is possible to fight their decision.
Surveillance: Insurance companies conduct surveillance by monitoring social media sites as well as hiring private investigators to look into your activities. If they have conducted surveillance on you and are using that information to deny your claim, it does not mean that they have caught you in a lie. Sometimes they jump to conclusions without making further inquiries to check for accuracy. Though they may try to use any information they can find to prove you are capable of doing your job, they are not necessarily right in their assessment. Talk to our team of disability lawyers to see how you can fight their decision to deny your disability claim.
It’s important to remember that claims adjusters are not on your side. Their main objective is to make sure they pay you as little as possible for your claim or find an excuse to deny it outright. A long term disability lawyer with experience working with insurance companies can assess what you are entitled to and work directly with the insurance company to secure those long term disability benefits for you.
Denied your long term disability benefits?
If you have been denied your disability benefits but you’re not ready to talk to our long term disability law firm yet, you can read through the Denied Disability Benefits page on our website.
If your long term disability claim has been denied, contact the long term disability insurance lawyers at Share Lawyers. Our 35+ years of experience in long term disability (LTD) law can help you win your case against Canada Life, Desjardins, Manulife, RBC Insurance, Sun Life, and other insurance companies. We offer free consultations and there are no fees unless you win your case. Join us on Facebook and become a Top Fan for a chance to win each month.
A note from our long term disability law firm
Taking a medical leave from work is not an easy decision to make. Concerns about providing for yourself and your family and keeping your job may cause you to want to push through your pain, but this won’t make your problems go away. Stopping work is often the smartest decision for your long term health and well-being, and your disability benefits are there to provide you with financial support until you can return to work.
If you have made the tough decision to stop working and apply for your short term disability or long term disability benefits, you may feel overwhelmed by the process and have questions that your employer and your insurance company are not able or willing to answer. Share is There to see you through and answer your questions in a free consultation.
Our experienced disability lawyers can fight back on your behalf
Share Lawyers believes that every client who is dealing with a disability claim deserves superior personal service. To achieve that goal, we have developed our team of experienced, compassionate, and caring long term disability insurance lawyers, law clerks, and administrative staff to meet all of your needs. Our team of experienced long term disability insurance, life insurance, employment, and critical illness insurance lawyers have made successful claims against many insurance companies, third-party administrators and employers.
If you are unable to work, your disability benefits should be there to provide you with the financial support you need. While your insurance company may be focused on finding ways to avoid paying your claim, our focus is on what is in your best interest. When Share Lawyers gets involved, you have an entire team of lawyers that are there to support you and to fight for what is yours.
Our disability claim lawyers fight for your disability insurance claim by relying on our many years of experience to apply the best strategic planning and approach in each case, using the latest technology available. Experience matters, and with Share Lawyers, you are in the best hands with 35 years of success on your side.
In this video, we explain the role of a long term disability lawyer and how we can support you when you have been denied your long term disability benefits.