The letter arrives on a Tuesday. After fourteen months of long-term disability payments, the insurer has decided you are no longer “totally disabled” under the policy and benefits will end at the close of the month. Your doctor has not changed her opinion. Nothing about your condition has improved. What has changed is the insurer’s view of it, and you are now expected to appeal, return to work, or go without income.
This is one of the most common situations we see in our disability practice, and the decisions made in the first few weeks after a denial matter a great deal.
Why denials happen when nothing has changed
Most group long-term disability policies use a two-stage definition of disability. For the first period, typically 24 months, you are disabled if you cannot perform the essential duties of your own occupation. After that, the definition usually changes: you must be unable to perform any occupation for which you are reasonably suited by education, training or experience.
A large share of terminations cluster around that change of definition. The insurer’s position is not that you have recovered, but that you could do some other job. Whether that is realistic for you is precisely the question the denial letter tends not to engage with.
Other frequent grounds include an insurer’s medical consultant disagreeing with your treating physicians on paper, a report from an independent medical examination arranged by the insurer, surveillance footage interpreted out of context, or gaps in treatment that are read as evidence of recovery.
Step one: read the denial and the policy
Ask for a complete copy of the policy or plan document, not just the employee booklet, and a copy of the insurer’s file, including the medical opinions it relied on. The denial letter will usually offer an internal appeal. Read the reasons carefully and identify exactly what the insurer says you can now do that you could not do before.
Step two: understand what the internal appeal is, and is not
An internal appeal asks the same insurer to reconsider its own decision. It can succeed, particularly where new medical evidence directly answers the stated reasons for the denial. But it is not a neutral process, it is not required before you sue, and, critically, it does not pause the clock.
In Ontario, a lawsuit against an insurer for denied disability benefits must generally be started within two years of the denial. Some policies attempt to impose shorter contractual limitation periods. Insurers have been known to let internal appeals run for many months, exchanging correspondence while the limitation period quietly expires. If you are pursuing an appeal, make sure someone is watching the calendar.
Step three: keep treating, and keep the record complete
Nothing undermines a disability claim faster than a gap in treatment. If you have been seeing your family doctor, a specialist, a psychologist or a physiotherapist, continue. If a referral has been outstanding, chase it. Ask your treating professionals to document not just the diagnosis but the functional limitations: what you cannot do, for how long, and why.
Keep your own record too. A brief daily note on symptoms, medication and activity is far more persuasive than trying to reconstruct a year from memory.
Step four: be careful with your employer and with returning to work
Do not resign. Resigning can end your coverage under the group plan and hand the insurer an argument that you chose to leave. If your employer proposes a return to work, get medical advice on whether it is appropriate and on what accommodations you need. An unsuccessful return attempt, properly documented, can support your claim; an undocumented one can be presented as proof you were fit.
Step five: know what a lawsuit can recover
If the internal process fails, the claim proceeds in the Superior Court of Justice as an action for breach of contract. The court can order the insurer to pay the benefits that were wrongly withheld and to reinstate them going forward. Where the insurer’s handling of the claim was unfair, courts have also awarded damages for mental distress and, in more serious cases, punitive damages. Most cases settle before trial, often through mediation.
If you have also applied for Canada Pension Plan disability benefits, be aware that most group policies deduct CPP disability from what they pay, and some insurers require you to apply. Whether to apply, and when, is part of the overall strategy.
What we do
Our disability benefits page describes how we handle terminated and refused long-term disability claims, from the first review of the policy through mediation and trial. Because the two-year limitation period runs from the denial, early advice is not a formality.
Get advice before the appeal, not after
If your long-term disability benefits have been denied or cut off, book a consultation with Kabir & Alam Lawyers before you respond to the insurer. We can review the denial, identify what evidence will actually answer it, and make sure the deadline that matters is protected.