Persons who seek legal advice in their claim for short or long-term disability often find themselves sorting through hundreds or thousands of pages to make sense of their claim.
During the process of retaining a lawyer, you will want to come to the table with key documents and information for your potential lawyer. This blog will help you understand what the key documents are and why they will matter in your case.
A long-term disability claim arises from a contract between the insurer and the “policyholder”. The contract can vary in length, but it contains many key pieces of information.
The definition of disability, the payment amount (usually a percentage of income), and other important terms will be contained in the policy. Your claims adjuster will have a copy of your complete policy and should share it with you.
Employees are often given a “policy booklet” or a similar document that summarizes the key details of the person’s coverage. While this booklet is better than nothing, it is only a summary – it doesn’t contain all the details. Your lawyer will need to provide you with a definitive opinion about your rights and obligations under the policy. It will save time if you ask the insurance company or your employer for a copy of the actual policy document so you can give it to your lawyer at or before your meeting.
Approval of Benefits Letter
If your claim was approved at any point, an approval Letter will explain when your benefits begin. It will confirm the definition in the policy that the insurance company believes has been met.
Lastly, an approval letter will specify the amount of benefits to be paid and when. Where the insurer has taken a long time to make the decision, the letter will also explain how any past-owing benefits will be paid.
Denial of Benefits Letter
If your claim has been denied, the Denial Letter should contain much more information than an Approval Letter. It should advise what the claims adjuster reviewed to make a decision and why that information did not result in an approval of the claim. If the adjuster sent your information to a medical professional, it should detail that professional’s opinion.
If the adjuster feels there is information they required but did not have, they should outline what that is. Sometimes family doctor records or specific tests like an MRI are important ‘missing pieces’ mentioned in a Denial Letter.
A Denial Letter will also explain what to do if a person disagrees with the decision. Insurers usually call this the “Appeal Process”. This is an informal process created by each insurer. They continue to manage the file but will consider an “Appeal” if you send them more information to review.
Change of Definition Letter
If you are fortunate enough to receive an Approval Letter and continue to be disabled for an extended period of time, you will usually get a letter as the two-year mark approaches advising of your “Change of Definition”.
In most cases, this means that you will be evaluated at a different standard starting at the two-year mark. This new definition should be outlined in the letter, but for many insured persons it switches at the two-year mark from an inability to do your “own occupation” to an inability to perform “any occupation”. As you might imagine, doing any occupation is a lower standard.
If you need help with a long-term disability claim in Ontario, consider retaining a member of the Ontario Trial Lawyers Association. Gather together the documents in this blog so they can help you get started on the right track as soon as possible.