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:
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.
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.
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.
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.
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.
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.