Long-term Disability Denied: How to Appeal in 7 Steps

Was your long-term disability denied? Were you getting payments, but now your long-term disability is terminated? If this sounds like you, then you are in the right place. In this article, I give you a 7-step process for how to appeal a long-term disability denial.

For a broader review of long-term disability benefits in Canada, check out our Ultimate Guide to Long-term Disability in Canada.

Nothing else matters if you miss the deadline to appeal your long-term disability denial.

Some appeal deadlines are soft, so missing them is no big deal. Others are hard. In other words: miss them, and you’re screwed. It’s not easy to tell the difference. So, it is best to assume that you have hard deadlines.

But how do you know the deadline?

If you got a denial letter from the insurance company, 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, you need to ask them to put the denial in writing.

The appeal deadline will either give you a specific date (April 2, 2022). Or, it will state a certain number of days from the date on the denial letter (30 or 60 days). If you are given a number of days, you need to look at a calendar and count each day out to find your deadline.

Here is an example of what the appeal deadline looks like:

Should you wish to appeal our decision there is a second and final level of appeal available to you. Should you wish to appeal at the final level, you are required to provide written notification of your intent to appeal within 30 days from the date of this letter. Any new or additional medical information to support your appeal must be submitting within 90 days from the date of this letter.

In this example, the insurance company gives two deadlines. The first deadline gives you 30 days to send a written notice of intent to appeal. The second is a full 90 days to get all the documents for the appeal. 

After denying your long-term disability claim, the insurance company will send a letter to your employer. It will tell your employer that your long-term disability was denied. And that you are able to work.

Upon getting this letter, your employer will likely call or write to you to ask when you plan to return to work. So, you have 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 need to do. They will allow you to be on unpaid sick leave throughout the appeal process of your long-term disability denial.

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, 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.

You need the 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.

Even though your long-term disability was denied, you may still qualify for other benefits. Also, the appeal can take months, so you need to work on a Plan B for other sources of income or financial support.

You may also qualify for employment insurance (EI) sickness benefits or creditor disability benefits on bank loans or credit cards. 

Before you can plan your appeal strategy, you must first identify the insurance company’s reasons for denying you. Insurance companies are required to give reasons for why they denied your claim. They are supposed to put these reasons in writing for you.

At this step, you want to identify the the reasons for denial. We recommend that you write these out on a sheet of paper. At Resolute Legal, we track the reasons for denial in a table. Then for each reason for denial you can identify possible responses and the evidence needed to refute the reason for denial.

Reason for Denial	Possible Responses	Evidence Needed

Vague Reason for denial, but requests specific information and documents

For example, here is the actual wording from a letter denying long-term disability where the insurer’s reasons are vague, but they give specific recommendations for the documents needed on appeal:

This type of denial letter is helpful because it gives your doctor specific questions to address in a new medical report. It asks you to have your doctor clarify the extent and severity of the diagnosis, prognosis, and treatment plan. It also asks for a copy of the doctor’s file from a specific date forward.

You would add it to your table as follows:

Reason for Denial	Possible Responses	Evidence Needed
“the objective medical information submitted does not support your absence from work and inability to perform the essential activities of your job”	Does the insurance policy require “objective” medical evidence New medical records that document objective medical evidence Medical opinion from doctor regarding diagnosis, prognosis, restrictions and limitations Functional capacity evaluation by occupational therapist to document restrictions and limitations Medical tests or evaluations to document objective medical evidence	1. medical report from doctor covering the following: extent and severity of diagnosis; objective medical information supporting diagnosis; prognosis; restrictions and limitations that prevent you from performing the essential duties of your job 2. family doctor’s clinical notes from Jan 23, 2020 onward 3. Clinical notes from any other health care provider from Jan 23, 2020 onward

Vague reason for long-term disability denial

Here’s another example where the reason for denying long-term disability is vague. However, the reference to the Transferable Skills Assessment gives you something to focus on:

In a situation like the one shown above, 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). Then, you can look for ways to show it was based on flawed information, faulty assumptions, or poor judgment.

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 consulting you. So, they can be full of errors or factual mistakes.

You would add it to your table as follows:

Reason for Denial	Possible Responses	Evidence Needed
We have completed a Transferrable Skills Analysis (TSA) which has identified the following gainful occupations you would be capable of performing with your current restrictions and limitations: 1) NOC 9461: Process Control Operator and 2) NOC 9214	Get medical evidence to show my restrictions and limitations are greater than the insurance company is saying Identify important factual errors in the TSA report that may have changed the writer’s opinion Identify missing information that may have changed the TSA writer’s opinion	1. Opinion letter from occupational therapist or vocational rehabilitation expert 2. Get my own Functional Capacity Evaluation to show that my restrictions and limitations prevent me from doing the listed jobs 3. Get expert review of the TSA to point out any errors with the report

“No reason” long-term disability denial

Finally, here’s an example of the worst reason for denial. I call it the “no-reason denial”:

As you can see, this letter provides no clear reasons for your long-term disability denial. Therefore, there are no specifics for you to focus on in your appeal. The insurance company doesn’t say what gap in information led to the denial. However, this denial mentions another letter. So, I would start by looking for that letter to see if it has more specifics.

Another option is to ask the insurance company representative to give more detailed reasons. But keep in mind, they may not agree to that.

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 your claim. Your best option in this situation is often to move on and take your appeal to court. 

If you are lucky, the insurance company will give specific reasons for the denial and may even list particular documents or information they need to reconsider their decision. Specific reasons are helpful because they mention gaps in the information you submitted. This makes the appeal easier because you know exactly what information to get them.

You need to identify the best document(s) to refute each reason for denial. These could be documents that already exist (like past medical records), or they may be documents that need to be created (medical reports or new tests, examinations, and evaluations).

Identifying the right documents is difficult. It requires a lot of practice and experience. However, the insurance company’s reasons for denying long-term disability often show a gap in the information or medical opinions provided. Ask yourself what document would fill that gap? Once you identify the document, you need to figure out how to get it.

For example, common gaps that need to be closed 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

The best documents are going to come from medical providers or others. Documents you create are the least persuasive. You may be tempted to do your own research, attach medical information you found online, or prepare a written statement. However, these types of documents are not convincing to the insurance company. It is best to always focus on getting documents from medical experts like your family doctor and other treatment providers.

Best Hack for how to appeal a long-term disability denial

If you are representing yourself, here is a simple hack to get a medical report that has a chance of addressing the insurance company’s reasons. First, make a photocopy of the insurance company’s denial letter. Second, go through the letter and underline each reason for the denial. There is usually two to three different reasons given. Third, number each reason as 1, 2, 3 etc. Finally, give this copy of the letter to your doctor. Tell your doctor you need them to write a report that addresses the “reasons for denial” you have underlined and numbered in the letter.

This approach can work because you are giving your doctor specific things to address in their report. This route is much better than simply asking the doctor to write another report without giving them anything to go on — other than the fact that your long-term disability claim was denied.

We recommend this hack over arranging for your own medical testing and functional capacity evaluations. We urge you do avoid doing that unless you are working with a disability lawyer. This type of evidence needs special care, and you could do more damage than good.

I find that this last step causes people the most anxiety. You may feel that if you don’t write a good appeal letter, it could result in your claim getting denied again.

Let me set your mind at ease. In the vast majority of cases, the appeal letter has almost no bearing on the decision. At this stage, the insurance company makes its decision based on the medical records and doctors’ opinions. 

So, your appeal letter only needs to do three things: request the appeal, attach the required documents, and 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 this on your own. Writing this type of appeal letter is hard — especially if you don’t have experience. 

You are better off avoiding legal analysis and focusing on writing about any information gaps. 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 in 30 to 60 days. If there are delays, it’s likely because the insurance company is waiting for their doctors to review the medical information you sent in.

If your appeal gets denied, you may have to repeat this process until you have exhausted all internal appeals or have the right to go to the next level of appeal. This level could be an appeal hearing or a lawsuit. However, the rules that apply to you depend on your insurance policy and/or collective agreement.

Originally published on June 13, 2021