LTD Denied after 2 years


#1

Hi there,
I was in a serious motor vehicle accident that left me disabled. I have been approved for CPP and I was receiving LTD until the 2 year mark. I have been deemed catastrophic with the MVA accident.

About the decision
Based on the information we have received and in conjunction with our health partner review.
The
information we have
received does not provide us with the clinical findings
that would support the
restrictions/limitations that would preclude you from performing any occupation.
That
is why we will
not be able to pay your benefit beyond
February 2, 2018

month period.

My doctor has claimed me totally disabled. My questions is, if i get legal representation and put a statement of claim against the insurance company, can i sue for them to pay until i am 65 for wrongful denial. How does this work?


#2

I am going through the same process. I would not waste any time (or day for that matter) with appealing their decision but lawyer up. You need Disability Lawyer to serve statement of claim and get the ball rolling stat.
In terms of how the statement of claim is prepared and what is included, that could be explained to you from an actual lawyer, like Resolute Legal team. But usually, they sue for breach of contract, punitive damages and reinstatement of benefits as per the terms set out on your policy.
Does your policy specify that after any occupation period starts you would be entitled for payments until 65? If so, then your lawyer would ask the insurance to reinstate payments as set in your contract.
However, since they cut you off on the 2 year mark, chances to get back on claim might be slim, they are likely looking to settle and get you out of their books like they do with everyone around the 2 year mark.


#3

Depending on your age it might not be good to settle.
You can sue for benefits to continue.
Whether your benefits go to 65 depend on your your policy.
A lot go to 65 but don’t assume that, what does your policy or benefits summary say?


#4

It states Jammer if I am totally disabled it is for life.


#5

Jam, why after the 2 year mark they try to get you off the books?


#6

At the two year mark the definition changes usually from “own” occupation to any occupation. They will usually review the materials to see if you are now disabled from all work at this time.


#7

Lawyer up. You have a very strong case as you have been approved for CPP disability. The appeal process is just an opportunity to try to clean up the file so that the denial looks reasonable. The denial letter does not give any reason for why they feel your documentation supports employment nor does it say what it is they think you can do.

Please, please consult with a disability lawyer and go for the free consult with Resolute -so you can either retain them or get a referral to a lawyer who knows what they are doing. Bringing in a lawyer now will save you much grief and they can take control and get your claim back on track.


#8

Thanks for your feedback allyoops. I appreciate this. I was told they would like to do a settlement with you when they take your claim like this. Why would i do this? If I am totally disabled and it happened at work a spinal cord injury, would it not be there obligation to pay me as my contract says until 65?


#9

Insurance is a numbers game. You do not make profits in paying claims. It is not personal against you.
If the Insurance Company denies a claim they save as most will not get a lawyer. Insurance Companies hope that if you do not give up that you appeal without a lawyers help. That way they can often use the time to delay your claim, wear you down and gather documentation to make themselves look or appear fair. You may even mess up and write a poisoned letter/email or do something that they can use against you.

A lawyer brought in now-at the first denial-can give you advice based on experience and education. This is a general forum of sharing experience. There are good posts within this forum that can help you if you choose to proceed without a lawyer.

Given your questions I am making the presumption that you do not understand how ‘the claim game’ works. My instinct is strong that you should get a lawyer’s advice before trying the appeal route yourself. By seeking out proper legal advice now you will have flipped the switch and put yourself in control of the claim.

Insurers are all about money. Lawyers cost them money.


#10

This is a rubber stamp statement that we see on many many applications. In fact, I just got off the phone with a person and her letter said the exact phrase was well.

Because of the timing of this termination of benefits (at the 2 year mark), your only realistic path forward is to bring a lawsuit against the insurance company. Or if your LTD plan prohibits lawsuits, you would need to appeal to the designated appeal board.

Assuming you have the option to sue, your appeal would go forward in that context and the options would be to negotiate a settlement, convince the insurer to voluntarily approve the appeal and pay benefits, or take the case to court and a judge will issue an order for approval / denial.

You should absolutely go forward with your appeal. Your situation is very common and can be turned around.


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.


#11

Thank you David. I appreciate you taking the time to answer my question. I was wondering where I can get your book? I would love to have a copy of it.


#12

I think fill out the form and ask for the book.
https://resolutelegal.ca/free-consultation/


#13

Why can a person not sue the bias doctors who fabricate test marks in order to satisfy an insurance company. They are in breach and it would normally cost them Thier job. They would pay out before a lawsuit to Dave there job. Or a psychiatrist hired by the insurance company who makes a psycic diagnosis based on his psycic intuition. They are the culprits responsible for wrongly denying claims. They would pay out much easier than risk Thier career.


#14

There are successful and unsuccessful claims against independent examinations and reports. It is typically easier to sue the Insurer and show the report was biased and not credible.

However if these Doctors were part of a rehabilitation or medical coordination plan recommended by your Insurer then you could sue for possible defamation, malpractice, invasion of privacy, and negligence and other claims.

You have to prove that the assessor owed you a duty of care, breached that duty and caused you loss/damage.
You could try for owed you a duty to be neutral and free of bias.

It does seem that more claims against Insurer chosen treatment providers and independent examinations are coming through the courts with mixed results.

In the past you could not sue an Independent Adjuster for property claims–but due to a few cases you now can.
The law keeps evolving.


#15

I see the courts are getting tougher on noticing the bias and incompetent proffesser also hired by the insurance company to use Thier license as a license to cause harm. I believe they should be held as a high priority within the breach and discrimination against an I’ll person. They should be held just as responsible/ equal to the discrimination upon people who become unfortunately I’ll. Punative damages should come into play.

I have no issues with the insurance company now, however, I do have the concrete evidence to stop a psychologist for defrauding government test results. If I go forward with my evidence this doctor would be out of a job in the legal aspect of his misconduct.


#16

My spouse is currently suing a psychologist and physical therapist whom he was referred to by the Insurer.
He almost took his life over it all. I am sure there are a lot of others who have experienced similar distress when referred to treatment for rehabilitation.

Any health professional who assesses you for treatment and provides treatment has legal and professional standards that should be adhered to no matter who is paying the bill. This includes informed consent, privacy and confidentiality and to disclose any conflicts of interest. No one should be treated as a lab rat.


#17

All I can say is diddo!!! Best of luck with the lawsuit! You are so correct


#18

I remain with two pettets in my head… And another disability for a lifetime. I got myself the highest powered gun I could get my hands on and my plan was to end myself by meeting this psychologist in the parking lot where he works. The college made a change by taking away the assigned parking spots and all psychologists names where removed. I thought what better way to bring in the media by shooting myself infront of a devious doctor that should have been fired after my complaint revealed his true misconduct and breach of his license.


#19

Doctors in Ontario only get a slap on the wrist for misconduct.


#20

I am so grateful that you did not end your life that way. I completely understand what it is like to disclose intimate details of how you are feeling and your innermost thoughts only to discover there is a non medical agenda in play. It is a very dehumanizing experience.

Remember what the psychologist did is not right on any level. Your life is worth so much more than any plan as you mentioned. Totally understandable why you felt that way.

Stay strong and take care of yourself. Others will read your posts and it will help them so that they know they are not alone. Karma will come but you may never know about it. It is exploitation -but that is on the psych-not on you.