LTD denied for Pre existing condition, do I have any hope?

Disability Insurance
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Hi im a 35 year old married man who lives and works in Toronto. I became ill earlier this year and I went on STD. My workgroup insurance agreed I’m disabled but denied my LTD benefit payment claim after my STD expired. They will however continue my drug, dental and massage/physio/chiro coverage. I was shocked when I learned about pre existing conditions, since when I took the job there was no mention of pre existing condition on the benefits package attached to my job offer. I had to ask our disability HR department to send me a copy of insurance booklet and finally found the pre existing clause buried in pages after page of lawyer language. They said since my doctor suspected my chronic illnesses a month before I got my new job, I triggered their pre existing clause. I called two lawyers from 2 prominent law firms here in Toronto but they wanted nothing to do with me and were almost rude after I sent them my denial letter and medical documents. I have applied for CPP-D and EI and i’m confident I will qualify but i think I will likely get max of $1,500 a month which is way too low for living in Toronto. That is almost a 80% decline in my income and it will be difficult to pay my rent which is already not that expensive at $2,500 for a 2 bedroom in toronto. I am trying to get rid of our car and everything i can sell i am. Thank god my wife works close to our home and she may be able to get a higher paying job soon. We also have savings for about 12 months if my wife was to lose her job too. Wondering if i have any hope in a lawsuit?

In my research I came across a court case related to pre-existing conditions that might be relevant to my situation:

  1. Tanious v. The Empire Life Insurance Company (2017 BCSC 85)
    https://www.canlii.org/en/bc/bcsc/doc/2017/2017bcsc85/2017bcsc85.html?autocompleteStr=tanious%20v.%20The%20Empire%20Life%20Insurance%20Company&autocompletePos=1
    This case involved a policyholder, Tanious, who was denied LTD benefits by Empire Life on the grounds of a pre-existing condition. The court ruled against Empire Life, finding that the insurer had not adequately informed Tanious of the pre-existing condition exclusion, and there were issues with how the insurer handled the claim.

I think this may open some avenues to a legal challenge against a pre-existing condition clause:

· Failure to Disclose : If I can establish that the pre-existing condition clause was not clearly disclosed or explained when I accepted the insurance coverage, which was when I signed the job offer which included my benefits package (made no mention of pre-existing conditions) we may have grounds to argue that the denial is based on terms that were not properly communicated to me?

· Inadequate Investigation : If insurance did not thoroughly investigate whether my current disability is solely due to the pre-existing conditions or if other factors are involved, we could challenge the fairness and adequacy of their decision-making process, similar to the issues raised in the Tanious case.

· Application of the Exclusion Clause : If there is room to argue that my current disability is not directly related to the pre-existing conditions or that the connection is not clear-cut, we may be able to contest the insurer’s application of the exclusion clause, drawing on the legal reasoning in Tanious.

Pre-existing conditions may be an unfair practice towards those with chronic illnesses and invisible disabilities, should they never change occupations or jobs? I don’t know this is all so complicated and the lawyers I have consulted don’t seem interested to help me at all.

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Can you share the actual preexisting language in your policy?

Did you apply for LTD within 2 years of starting your new job?

Most lawyers (who don’t specialize in LTD) know nothing about LTD, so not surprised with how you were treated.

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Yes i joined the new company only recently in January for better pay and remote work. Unfortunately my condition became considerably worse and worse since february and by late March I could no longer work. Both the lawyers i contacted were disability lawyers and were unhelpful. I haven’t contacted resolute legal yet .

Your long-term disability plan has a provision which states that no benefits are payable for a disability
arising from a disease or injury for which you received medical care before you became insured. Medical care is received when you see a doctor, use medication on the advice of a doctor, or receive other medical services or supplies.
This provision does not apply if disability starts after:
a) you have been continuously insured for one year; or
b) you have not had medical care for the disease or injury for a continuous period of 90 days ending
on or after the date your insurance took effect.
Your long-term disability insurance coverage became effective on January 3, 2024 and your disability prevented you from working on March 15, 2024. Because you have not been insured for at least one continuous year before your disability began, we look to see if there is a continuous period of 90 days where you have not received medical care for your disease or injury. The period we investigate starts on October 3, 2023 and ends on March 19, 2024.
Because there isn’t a 90-day period where you did not receive medical care for your condition during the period of time we are required to investigate, we are unable to accept your claim for long-term disability payments.

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As much as I don’t like how many insurance companies deal with their claimants, I would agree with this denial if provisions a) and b) are indeed in your master policy.

That said, definitely have resolute review your denial and master policy. I know of one denial based pre-existing condition clauses that was reversed very quickly because when the insured got their master policy there actually weren’t any pre-existing clauses in it.

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Thanks yes both clause A and B are true but my concern was mostly with the lack of communication of the pre existing clause to me and fairness although i understand those are challenging to dispute. The conditions were not listed when i signed up for coverage aka i signed the job offer and benefits package.

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To get a lawyer to tackle this you may need to pay hourly, as the prospect of winning (I believe) is slim to none for a lawyer to do it on a commission basis…but I wish you luck.

The only advice I can give, is if you find case law that supports your position then reach out to the law firm that handled that specific case. If those lawyers aren’t willing to represent you then I’d say you’ve hit a dead end.

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Thank you. I’ve found some cases but it appears that the lawyers and law firms are protected and not publicly accessible. However I’ll do my best. Even if it ends up costing a lot I’d rather raise awareness about the dangers of pre-existing condition clauses similar to how the ACA 2010 addressed pre-existing conditions in the US - albeit for health coverage vs disability in Canada.

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So you had an issue you knew about. Got a job, worked a month youre surprised that they didnt approve you?

Come on man. Im all for disability. Im on it myself, however i did work for my company for 12 years.

Im pretty sure every company insurance will have a clause like this. Why wouldnt they?

It states after a year you would have been alright, but you paid into the insurance for a month and expect them to pay you for life

You have cppd and I’d say to apply for provisional disability. There is no way a lawyer will take your case and no way youd win.

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Patient0, I’m curious. Had you known about the pre-existing clause what would you have done differently?

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Hi,

I know this is a few months old but just wanted to say that i got denied for pre existing condition and did end up getting it approved.

But it took 8 months, a LOT of work, a lot of time, a lot of reading and a lot of carefully asking questions, trying to think of every possible angle. Asking questions to slowly back them into a corner without getting myself stuck in that corner. Taking their answers and probing, focusing on the holes. Having to “coach” my doctor on how the forms had to be filled out, having a specific framing to make everything fit.

I spent a lot of time trying to find anything that could be similar enough to my situation on canlii, i read the policy over and over and over again. In the end, I got them to a point where they hadn’t given me satisfactory answers about their interpretation and the denial but they couldn’t say anything more without sounding ridiculous. They simply stopped responding completely and stopped answering my questions.

Anyway, it would depend on the situation. I won because i had multiple diagnosis, one of them was pre existing, the other was not. I was able to clearly show that it was in remission & treatment was maintenance, so i challenged whether it was truly pre-existing.

Also, they were telling me that because symptoms of both conditions overlap, they were considering both pre-existing. Which is absurd because if they can’t prove the symptoms were related to the new diagnosis, obviously i have no way of proving they don’t. Even a doctor can’t,.

Also, the contract doesn’t say anything about pre-existing symptoms, it covers conditions - not symptoms. They said all kinds of things when i was asking questions and couldn’t walk them back later on but it made no sense, they were backed into a corner.

Anyway, I threw all of that (and more) at them. It was part of a complaint i sent to the ombudsman so it had lots of info - its like 30 pages, its insane, i was on a mission lol but i took so much put of me.

I got an approval, an apology and i was told the case managers would get coaching. I was told the legal department said i was correct about the multiple diagnosis. Even if one is pre-existing, if one is not, then it’s valid.

So basically, it depends on your situation. And if you have the energy to put into it. I was angry the whole time, that’s what was driving me.
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Edited to add: I just saw another thread where i discussed this HERE

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Just wondering… Did you pick when you became disabled? I didn’t. I didn’t get a choice or an option to reschedule. I don’t know this person so i can’t speak for them but frankly, neither do you.
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Have you ever heard of episodic disabilities? Maybe you should get better informed.
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Increasing numbers of Canadians are living with episodic disabilities. A person can simultaneously live with both permanent and episodic disabilities; however, there are clear distinctions. An episodic disability is marked by fluctuating periods and degrees of wellness and disability. In addition, these periods of wellness and disability are unpredictable. As a consequence, a person may move in and out of the labour force in an unpredictable manner.

What are some of the challenges of living with episodic disabilities?

Definitions:

Definitions used in legislation, by medical and rehabilitation providers and by insurance providers and government benefit programs often focus on permanent disabilities. They can also differ from one source to another creating barriers to accessing and coordinating programs and benefits for people with episodic disabilities who need access to various income support programs.

Care, Treatment and Support:

The health care system and service providers are often not well equipped to handle the needs of people living with lifelong episodic disabilities. The unpredictability of the illness can be challenging to the care provider and a person’s self-esteem. Goals are difficult to set. Depression is common. Care and treatment can be compromised when it is dependent upon income-support and benefits programs that are not flexible.

Workplace Accommodation / Employment Issues:

Part-time work and flextime are critical components. Employer associations, insurance industry representatives, governments, unions and disabilities communities need to coordinate, collaborate and contribute to plans that accommodate the needs of those living with episodic disabilities.

Income Support and Security:

The threat that disabilities benefits may be “cut off” during periods of improved health, then be difficult to reinstate later during periods when health status declines may create fear of loss of benefits and non-reinstatement, and be a disincentive to return to work. In addition, complicated claim procedures may need to be repeated every time someone needs to be absent from the workforce for a period of time that is more than allowed. For these reasons, flexibility is very important in an income support program that is going to address episodic disabilities.

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