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To appeal or not to appeal?
That all depends.

Good idea or waste of precious time?

 

If you applied for long-term disability benefits and your insurance company denied your claim or if your insurance company terminated your benefits, you may be wondering what options are available to you.

 

Generally, whether your LTD benefits are provided under a group benefits policy or through an individual (private) policy, you will have two options:

 

1. Appeal the denial or termination of your claim by providing new information to the insurance company to support your appeal.

2. Court Action against your insurance company.  There is not typically any requirement for you to first appeal the decision before commencing legal action through the courts.

 

In determining which option is best for you, there are many considerations which are unique to you and your case. In all cases, will start by reviewing three key pieces of information:

1) the time limit for starting your court action (the two year limitation for litigation starts from the date of the first denial or when benefits first became payable);

2) the reason for the denial; and

3) the evidence available or attainable necessary to successfully dispute the denial.

 

If you are unsure whether you should appeal or commence litigation, contact us and we will review the denial with you; obtain details about your case; and provide with information, insights and suggestions to help you determine the best way to proceed for you.

Courtney Mulqueen has over 20 years experience representing clients in long term disability disputes. If you choose to appeal your insurer’s decision, we can provide a range of services to assist and set you up for success (some at no cost to you). Below, we provide an overview of the appeal process and how we can help. For a more detailed guide to appealing a denial or termination of long-term disability benefits, please see our Appeals Guide.

What is an LTD Appeal?

In the letter denying or terminating your benefits, your insurance company likely offered you the option to appeal the decision, setting out a list of documents that you or your doctor would need to submit in order for you to appeal.

The insurance company will review the new documentation you submit and decide whether the new information is sufficient to change its decision and reinstate or approve your benefits.

If your appeal is successful, your benefits will be paid from back from the date the insurance company stopped paying your benefits or from when you were first entitled to benefits, based on the date of your initial claim. You will then continue to receive disability benefits on a monthly basis, so long as you continue to meet the definition of disability and satisfy the other conditions in the policy or until they decide to stop paying you for whatever reason.

 

You do not need to appeal the decision in order to proceed with litigation.  For some clients, once their claim is denied they are quite happy to proceed with litigation with the goal being to achieve settle on lump sum settlement (a "divorce" from the insurance company) as opposed being back "on claim" and in an ongoing relationship with the insurance company, which would be the outcome of a successful appeal.

Do I need a lawyer for an Appeal?

You may or may not need a lawyer to help you or do the appeal for you. If the basis for your appeal is complicated or if dealing with the insurance company is a major source of stress and is impacting your mental health, you may decide it is worth it to hire us to do your appeal for you or to help you do it yourself.

 

Most people who do choose to appeal (rather than litigate right away) are able to appeal the decision on their own or with some guidance from us. We provide various levels of assistance with your appeal, depending on your individual needs.  We are able to provide you with valuable information, insights and suggestions during our initial consultation (free) which will help you do the appeal or decide if you would like for us to do it for you. 

If your long term disability claim has been denied or terminated for any reason, we encourage you to contact us. We will review your case together; provide you with information and insights; and help you decide whether to submit an appeal or to start a court action against the insurance company. We will also help you decide if you need legal help with your appeal, and if so, which type of assistance would be most beneficial.

What can you do to help yourself with your appeal. 

If your long-term disability claim has been denied, it can be a frustrating and challenging experience. However, there are steps you can take to appeal the denial and increase your chances of getting the benefits you deserve. We encourage you to look at our Disability Appeals Guide

 

Here are our Top Six Tips for Appealing the denial of a long-term disability claim:

  1. Understand the reasons for the denial: When you receive a denial letter, carefully review the reasons for the denial. This will help you understand the insurer's position and identify any gaps or weaknesses in your claim.

  2. Gather additional medical evidence: If your claim was denied due to a lack of medical evidence, you may need to gather additional documentation to support your claim. This can include medical records, test results, and statements from your treating physicians.

  3. Get a second opinion: If your claim was denied based on the insurer's evaluation of your medical condition, consider getting a second opinion from a different doctor or medical specialist. This can help provide additional evidence to support your claim.

  4. Hire an experienced disability lawyer: A disability lawyer can help you navigate the appeals process and provide expert guidance on how to build a strong case. They can also help you understand your legal rights and ensure that the insurer is acting in good faith.

  5. File a timely appeal: Be sure to file your appeal within the deadline specified in the denial letter. Missing this deadline can jeopardize your chances of obtaining benefits.

  6. Be persistent: The appeals process can be lengthy and frustrating, but it is important to remain persistent and continue to advocate for your rights. Keep detailed records of all communications with the insurer, and don't hesitate to reach out to your lawyer for support and guidance.  If your appeal is denied, your records will be important evidence for us in your court case.

Remember, the appeals process can be complex and challenging. It is important to seek expert legal advice and be prepared to invest time and effort in building a strong case.

We can help with your Appeal.

If appealing to the insurance company is the best option for you; if your claim is complicated; or if continuing to deal with the insurance company on your own is taking a toll on your health, we can help. Knowing what information the insurance company needs and how to present that evidence in a persuasive way, can increase the chances of a being successful on your appeal.  It while also allowing you to focus on your health and recovery, distancing you from the stress of dealing with the insurance company.

We can assist in your long-term disability appeal in several ways, including:

  • Reviewing your termination or denial letter, insurance policy, claims file and medical records to determine the best strategy for appealing the decision.

  • Determining what evidence of disability is going to persuade the insurance company to approve your benefits.

  • Obtaining the information you need for your appeal or advising you what information you should obtain.

  • Drafting or helping you draft a cover letter for your appeal, detailing the basis for your appeal and summarizing the new information that you are providing;

  • Taking over communications with the insurance company on your behalf or participating in communications between you and the insurance company, during the appeal process.

  • Commencing litigation if you decide, in the process of appealing that it was not the right decision for you. 

Helping you with your appeal, means that we will already know your claim inside and out.  If your appeal is later denied, we can start the litigation right away, saving you time and money.  If your claim is approved on appeal with our assistance we will do a "happy dance" with you and be proud to have played a role in the positive outcome.  We know that you will be happy to refer us on to others who need our help and that if you need us later on, we know you will come back to us for assistance.  At Mulqueen Disability Law we feel strongly that we rise by lifting others.

Contact

3042 Bur Oak Avenue, Suite 2,  Markham, ON  L6B 0R1

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We promise to be in touch, shortly.

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