I wrote this article for people who need to appeal a recent denial of long-term disability benefits. It gives you a 7-step process for doing your internal appeal.
Has the insurance company denied your claim for long-term disability? Are you still getting payments, but worried they could be cut off soon? Are you in a panic mode, wondering what your next move should be?
If this sounds like you, then you are in the right place. Appealing your long-term disability denial is a seven-step process:
- Step 1: Identify the deadline for appeal
- Step 2: Enforce your employment rights
- Step 3: Gather documents needed to plan your appeal
- Step 4: Identify other benefits you could apply for
- Steps 5 and 6: Analyze the denial letter and identify documents needed for the appeal
- Step 7: Prepare and send your appeal letter
- Next Step
For a broader review of long-term disability benefits, check out our Ultimate Guide to Long-term Disability in Canada.
Step 1: Identify the deadline for appeal
Nothing else matters if you miss the deadline to appeal.
Some appeal deadlines are soft (no big deal), while other appeal deadlines are hard (miss them and you are screwed). It’s not easy to tell the difference, so work on the assumption you have hard deadlines.
So how do you know the deadline?
If you got a letter from the insurance company denying your claim (denial letter), then the deadline for appeal is usually included in the last few paragraphs of the letter. If the insurance company didn’t send a denial letter, and just informed you over the phone, then you need to ask them to put the denial in writing.
The appeal deadline will either give you a specific date (e.g., April 2, 2020) or it will be stated as a certain number of days from the date on the denial letter (e.g., 30 or 60 days). If you are given a number of days, then you need to look at a calendar and count them out to find your deadline.
Here is an example of what the appeal deadline looks like:
In this example, the insurance company gives two deadlines: 30 days to give written notice of intent to appeal, and then a full 90 days to get all the documents for the appeal.
Step 2: Enforce your employment rights
When your claim is denied, the insurance company will also send a letter to your employer. The insurer will tell your employer that you are able to work and don’t qualify for long term disability.
Upon getting this letter, your employer will likely call or write to you to ask when you plan to return to work. So, you need to inform your employer, in writing, that you disagree with the insurance company and are appealing their decision.
For many employers that is all you will need to do. They will continue to allow you to be on unpaid sick leave while you are appealing the denial of long-term disability.
However, some employers will take a more aggressive approach. They try to rely on the insurance company’s opinion that you can work, and demand that you return to work. They will warn that failure to return to work will be viewed as abandoning your job, or something to that effect.
If you are dealing with an aggressive employer, then you need to have your doctor write a new off-work note directly to them. This note or letter needs to clarify that that doctor continues to put you off work, regardless of the insurance company’s opinion.
Once you give the employer an updated sick note, it will trigger your rights to ongoing accommodations under employment and human rights laws. A reasonable accommodation is to allow you to continue on unpaid sick leave.
For more information see: Employment rights and disability benefits.
Step 3: Gather documents needed to plan your appeal
You need information to understand the denial and to plan your appeal. We recommend you get the following documents:
- A denial letter from your claim representative
- A copy of your group insurance booklet, which describes your long-term disability benefits
- A copy of the insurance company’s “claim file” (if your claim is more than six months old)
- Your union’s collective agreement (if applicable)
- A copy of your family doctor’s medical file, going back to when your symptoms started to affect your work
The purpose of these documents is to help with planning your appeal. However, your family doctor’s medical file also serves as proof of your claim. Make sure you keep a clean copy of the family doctor’s file to send to the insurance company.
Step 4: Identify other benefits you could apply for
It can take months to successfully appeal a long-term disability denial. So, you need to work on a Plan B for other sources of income or financial support.
You should consider if you would qualify for employment insurance (EI) sickness benefits or creditor disability benefits on bank loans or credit cards.
Steps 5 and 6: Analyze the denial letter and identify documents needed for the appeal
Before you can plan your appeal strategy, you must first identify the insurance company’s reasons for denial. Insurance companies are required to give reasons for why they denied your claim. They are supposed to put these reasons in writing for you.
If you are lucky, the insurance company will give very specific reasons for the denial and may even list specific documents or information they need to reconsider their decision. Specific reasons are helpful because they mention gaps in information from your doctors or information you have given. This makes the appeal easier, because you know exactly what information to get them.
The insurance company’s reasons for denial often point to a gap in the information or medical opinions provided. You can win the appeal by filling that gap. You can do so by providing the missing information or medical documents to the insurance company.
Common gaps that need to be filled include:
- clarifying a medical diagnosis
- clarifying functional limitations
- explaining exactly how your symptoms and limitations prevent you from doing the job
- clarifying information about job requirements or physical demands
- providing copies of records or reports from other treatment providers
- obtaining new medical evidence
- obtaining information from co-workers or family members
- clarifying your work history
Here is a sample denial letter where the insurer’s reasons are vague, but they give specific recommendations for the documents needed on appeal:
This type of denial letter is useful because it gives your doctor specific questions to address in a new medical report which you can send with the appeal. It asked the person to have their doctor clarify the extent and severity of the diagnosis, prognosis, treatment plan, etc. It also asked for a copy of the doctor’s file from a specific date forward.
This is the easiest situation because you can give the denial to your doctor and they can do a report answering the questions and provide a copy of their file.
Here is another example, where the reason for denial is vague, but the reference to the Transferable Skills Assessment gives you something to focus on:
In a situation like this, the insurance company is not listing documents or information to give on appeal. However, there is a clue about how you could focus your appeal. If I were advising a client, I would ask for a copy of the Transferable Skills Assessment (TSA) and look for ways to show it was based on flawed information, faulty assumptions or poor judgement.
For example, you could also get your doctor to review the TSA and offer a critique.
Or you could review the TSA and write a statement pointing out all the factual errors or flawed assumptions within the report. Often these TSAs are done without any consultation with you, so they can be full of errors or factual mistakes.
And finally, here is an example of the worst type of rationale for denial. It is what I call the “no-reason denial”:
As you can see, this letter provides no clear reasons, and therefore no specifics for you to focus on in your appeal. The insurance company is not saying what specific gap in information led to the denial. This denial mentions an earlier denial letter, so I would start by looking at that letter to see if there was more specific information provided therein.
Another option is that you could ask the insurance company representative to give more detailed reasons, but they may not agree to do so.
In a case like this you may need to review the insurance company’s claim file to see what is really going on. Sometimes in a “no reason” denial situation, the insurance company has completely closed its mind to approving your claim. Your best option in this situation is often to just move on and take your appeal to court.
Step 7: Prepare and send your appeal letter
I find that this last step—writing an appeal letter—causes people the most anxiety. You may feel this way too. You worry that if you don’t do a good job, it could result in your claim being denied.
Let me set your mind at ease. In the vast majority of cases, the appeal letter has almost no bearing on whether they will approve or deny your appeal. At this stage, the insurance company bases its decisions on the medical records and opinions you’ve supplied.
Your appeal letter only needs to do three things: 1) Say that you are asking for an appeal; 2) Attach the required documents in support of your appeal; and 3) Arrive at the insurance company before the deadline.
Ideally, you would review the key facts and then apply the law to show why they should approve your claim, but I recommend against trying to do this on your own. Writing this type of appeal letter is hard to do—especially if you don’t have experience with written advocacy. I have seen more bad examples than good examples of people trying to do this.
You are better off to avoid legal analysis and to focus on writing about any gaps in information. This could include:
- Clarifying any misunderstandings about your medical treatment or employment
- Reviewing all the things you did to try and stay at work
- Discussing how your symptoms affected your duties
Once you have sent in your appeal letter, you will usually get a response within 30 to 60 days. If there are delays, it is likely because the insurance company is waiting on their doctors to review the medical information you sent in.
If your appeal is denied, then you may have to repeat this process again until you have exhausted all internal appeals or have the right to go to the next level of appeal. This next level of appeal could be an appeal hearing or an appeal by lawsuit. The rules that apply to you will depend on your insurance policy and collective agreement (if you are in a union).