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:
- 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.