My LTD application was denied - “While we acknowledge that you have a medical condition and experience symptoms, the information on file does not support a severe medical impairment that prevents you from performing your essential occupation duties as Customer Experience Representative. As such, you do not meet the definition of total disability.” I cannot agree with this as I can’t even stand on my feet for longer than a hour without muscles seizing up, knees going weak resulting in a limp, and sometimes even a foot will go numb with accompanying sciatica and the job requires me to be on my feet 8 hours a day, 5 days a week. Has anyone had luck appealing a LTD denial without having a diagnosis but with explaining their symptoms? How did you list your symptoms, what phrasing did you use?
Another question. If I’m unable to get Medavie Blue Cross more information than they already have within the appeal window and the claims is closed. If I decide to re-apply and somehow get it approved, would the reimbursement of my pay go back to start of when I began my medical leave from work or just to the start of my application?
My apologies and gratitude to those who read and help out! This whole situation has totally exacerbated my anxiety and I’ve put off asking these questions for too long, essentially shooting myself in the foot 
I think they would expect you could do a different job or have accommodations made for your current position. Without a diagnosis its very hard. I myself is waiting on a CPPD decision for over 6 months now and i have 5 different diagnosis and not sure if it will be a positive outcome or will i need to appeal. I wish you much luck on your appeal.
It’s a retail position so there’s no opportunity for sit-down positions like I would need. I agree though, very hard. It’s been over a year of testing, theorizing, trying different therapy (while I still had the money) and I’m even worse than where I started.
Best of luck to you with your journey!
Do you have the support of a doctor or some other medical professional?
From my experience…
Take a list of the essential duties of your occupation. Then make statements on why you are no longer able to do each of them for a sustained period of time. It could be the combination of the esential duties is what is causing the problem. If you’re anything like me, doing only a few of the essential duties of my occupation for an hour a day is doable for about week, but I’d be bed ridden for a week after. The LTD insurer needs to know things like that. Send them a letter stating all of this. You need to tell a clear narrative of your situation (write a detailed lengthy letter explaining things from your perspective) and why you have stopped working because your pain symptoms are too much. You don’t need a specific diagnosis, unless otherwise stated in your policy, as legally your symptoms determine your eligibility for LTD not a diagnosis. It helps to tell them everything you’ve tried that didn’t work to stay at work. Take your time in writing this letter.
Then, give a copy of your letter to your doctor, and then get your doctor to draft a letter supporting you, and have them state directly that “Mr/Ms X is no longer able to perform the essential duties of their occupation due to their significant pain symptoms. Mr/Ms X meets the contractual definition of Totally Disabled under their LTD policy”. Make sure your doctor knows what the definition of Totally Disabled is for your policy. Most doctors think totally disable means you’re in a coma or paralized…all it means is that you can’t do your current job…check the wording of your policy.
Put it all together and send it to your LTD insurer. Give them a 3 week deadline to respond. I put this statement at the end of my letter to them. “With this additional information my expectation is that INSURER X will come to the reasonable conclusion that I meet the eligibility requirements to receive LTD benefits by (insert date). I trust that I won’t need to involve my legal counsel to enforce my legal rights under this LTD policy”.
If you are denied again or don’t hear back at the 3 week deadline get a lawyer that works on contingency basis (all the experienced LTD lawyers work on a contingency basis). Any half decent lawyer will get you financial compensation from the LTD insurer as long as you have the support of your doctor to be off of work.
Yes, my doctor is in agreement that I’m unfit to go back to work. She’s been willing to help out with forms as well, but unfortunately doesn’t have much faith my appeal will be approved since there’s nothing new to add to her statements/ “detailed narrative” as MBC likes to put it.
This is amazing amazing amazing information, thank you!
So I’ve looked through my policy again and it states, “a Member is Totally Disabled for the purposes of this benefit if the Member is completely and continuously unable to perform the Regular Duties of their own occupation as a result of Illness or Accident.”
The ‘as a result of illness’ worries me. Would/Could MBC use that as reason to deny me, saying I don’t have a diagnosed illness?
Hello again. An illness just means you are in poor health. An illness can occur without a diagnosis. If you have a collection of symptoms causing you poor health that prevents you from doing your job, then you are ill, and therefore have an illness. It’s just happens to be an undiagnosed illness. History is filled with people that have had illnesses that took years before any type of disease was attributed to the symptoms. The courts support this as well.
With your doctor’s support get the letters to the insurer asap. Be very assertive with them. Give them 3 weeks to fix their mistake, after that lawyer up.
Since you have your full doctors support you are in great shape to fight back with the help of a lawyer if they do end up denying you again. Again, make sure you get a lawyer that works on contingency…if you get lawyer who says they need a large retainer for an LTD lawsuit then they probably have no idea how to properly do a LTD lawsuit.
I also forgot to mention your LTD policy should also have a definition of illness.
You need to be specific about how your illness makes it impossible to work. Show how you tried to keep working and what the results were (debilitating pain and suffering). Explain how difficult it is to do your job effectively while in pain.
Perhaps get a copy of the job requirements that were sent to your LTD provider. Perhaps there’s a disconnect between what your job really is and what they state it is.
I’ve never appealed a claim, fortunately mine was approved from the start as I followed the guide that Resolute provides and told the story, leaving them without little to no further questions on my application. I too don’t have a formal diagnosis aside from GAD, but I’ve been referred to specialists for other health issues resulting from the original diagnosis.
If my claim was denied after carefully following the guide; I would get a lawyer on it asap.
A lot of employers make accommodations for retail employees in wheel chairs.