Best way to go forward after denial

As I had anticipated, my claim was denied due to a pre-existing condition even though I had clearly indicated (as did my doctor) that the existing, chronic condition was not the cause of my disability and that the reason for my claim was a new diagnosis listed as “primary diagnosis”. Somehow they conflated the two and denied based on this.

I am definitely not in agreement with their decision so I am considering appealing.

However… I had another idea but I am not sure if it’s possible.

I first went on medical leave from work a couple of months short of my 1 year of employment and returned approximately 6 weeks after the 1 year mark. After a failed attempt at a progressive return, I went on medical leave again 3 weeks later.

I used the date of my first leave for my claim, as that covered the 13 weeks elimination period. This is why the pre-existing condition exclusion was used.

However had I used the start date of my most recent leave, I would have been passed the 12 months of coverage.

Is this correct?

If so, can I make changes to my current claim, or submit a new one with the later date?

I don’t think it’ll matter about the date.
You had been at the current employer for a year.
I seem to remember something about insurance companies being stricter when an employee hasn’t been working 2+ years (maybe the pre-existing clause doesn’t apply after this time).
Your best bet is to get the free consult with Resolute.

When they have already identified this as a pre-existing condition denial you are going to have to get a lawyer. I would not do what you propose until you get legal advice because it could just make things worse.


David Brannen

Disability Lawyer with Resolute Legal

The response posted above is based on the limited factual information made available and is not intended as a full and complete response to the question. The only reliable manner to obtain complete and adequate legal advice is to consult with a lawyer, fully explain your situation, and allow the lawyer enough time to research the applicable law and facts required to give an adequate opinion. The basic information provided above is intended as a public service only, a full one-on-one discussion with a lawyer should be done before taking any any action. The information posted on this forum is available to the viewing public and is not intended to create a lawyer client relationship with any person. If you want one-on-one advice, please click here to request a free consultation or call toll free 1-877-282-5188 to speak with a member with our disability claim support team.

I’m unionized and trying to get support. Hopefully I’ll hear back soon.

I’m in Québec and most lawyers I find online who offer free consultation do not cover Quebec.

Their claim that one pre-existing condition caused the other disabling condition is a subjective assumption. They don’t provide any evidence that it is the case.

The request for additional medical information that followed my initial submission consisted of almost identical questions (word for word) that were already answered in the questionnaire.

The request letter was sent to my doctor in English even though the initial form, all of the provided records, including doctors notes were provided in French because my doctor is clearly French speaking. Her response to the English request was also written in French only… She evidently did not catch any nuances. Seems unfair.

That happened to my friend and his appeal consisted of “see page x of the initial submission for the answer”.

Was the appeal successful?

His appeal was successful.
That was a few years ago though.
I suspect it is generally getting harder and taking longer than it used to.
That is why I think they don’t read applications the first time sometimes.
Best wishes.

From the denial letter, it is clear that they do not put much time into reading the Complete application. I think they look for any crack that gives them an opportunity to deny and they shut it down without even trying to consider the whole of the application.

They clearly have the upper hand and all the tactics. I mean, unless you are experienced in the claims game or your case is straightforward, you’re kind of doomed. How do you stand a chance, at least on first try, when they are the ones who make the rules and only tell you after the fact that you have broken them. Not only that but they don’t actually tell you what the rule is or how you broke it.

That’s the set up. Now you can appeal but who knows what you are supposed to contest, prove, disprove or argue… That’s why they don’t actually provide definitions for many confusing and ambiguous wording and don’t tell you what criteria they use to determine that these apply to your case.

They can choose whatever interpretation is convenient! You can’t object because you were never given a definition.

It’s such an injustice to bully people who are in need, vulnerable and already struggling. Even if I don’t succeed, I’m going to pursue this until the end. It makes me so angry, this has basically destroyed my security, it’s affected my health as well as my life and they can’t even bother to look at my claim thoroughly?! I do think I will eventually win, even if it takes going to court.

Sorry, really had to rant. It’s not right.

I think you can request your claim file from Service Canada and it might provide insights.
I don’t know the time frames though.
David has written articles on how to appeal.

I’m not appealing CPP, I’m appealing my claim for LTD under a group insurance plan.

I did request and have received my file from the insurance company but there isn’t much in there. They really just selected a tiny bit of information without even looking at the rest and used it to deny and decide there was no need to go any further. It’s obvious because the information they didn’t bother to look at presented the facts in a completely different way. If the claim is reviewed properly, their interpretation and the reasons they provided in the denial letter make absolutely no sense.

I would make an appointment with a lawyer for a consult. They may guide you in what to write for an appeal or they can write up an appeal letter on your behalf and deal with the insurance company, taking the stress off you.
The job is to save the insurance company money. Their actions can make it seem like it’s a game or a personal attack and sometimes it does drag out. It’s usually the same forms for your doctors to complete, asking the same questions to gauge any change in your medical condition.

You need to ensure that you carry on with ongoing treatments, medical appointments, medications and the like. No tricks or games on your end. Good Luck!