Obtaining a copy of your own file /Issues with Claim Specialist


#1

Hi,
I’m currently on LTD through my works insurance and I’m coming up to my two year mark now and so far these year they seem to be doing everything in their power to undermine me, luckily I have the backing of a great team of medical professionals who back me up so they’ve been unable to force me into rehabilitation and have now said they’ll be calling me for IME’s etc. I’m having issues getting any response from my claim specialist. I requested my file back in Jan, not only has it still not been produced but he refuses to give me an estimated date for when to expect it, I received all this review paperwork for myself and my GP to fill in yet there was no date mentioned for when it is due back to them by, I have emailed him several times over the past month to ask for a date and he still hasn’t responded which isn’t anything new but I’m afraid I’ll miss dates for paperwork and they’ll use this against me somehow. They also told me under no circumstances was I to apply for CPP but I’m starting to think that wasn’t advice I should have listened to either.

Q. Legally do insurance companies have to provide me/my gp with my file and do they have a time period by which they have to do so?
Q. If you’re having problems with your claim specialist, what is your best course of action, how do I get a response to my questions?

I truly would appreciate any advice, I feel without knowing my legal rights that I’m extremely vulnerable to their version of events and so far, disingenuous advice.

Thank you in Advance


#2

Not a lawyer -but my thoughts.
Did you ask for the claim file in writing-complete and full copy?
You can send in a request under PIPEDA -then they have 30 days
I only talk to my husbands insurer via email/fax or registered mail. Never by phone!
You can request another claims specialist given that he is not responding to your requests. Or his Manager.
Typically your Doctor has 30-60 days to fill out documents.
You should also request the Master Policy.
If your Doctor supports you to apply for CPP-D then do so.
If they will not give you a date for forms then send them a letter and tell them what date you will send them.

Just stay humble and helpful-but firm.
Did you get it in writing them telling you under no circumstances to apply for CPP-D? They have no right to do that


#3

Alleyoops knows her stuff and I agree with what she is advising.

They have no right to say you cannot apply for CPP-D and cannot hold that against you.

If your LTD rep / insurer are non responsive you can always complain to the insurance regulator for your province. Often called the superintendent of insurance. That will get their attention.

You have a legal right to your docs via provincial freedom of information legislation.


#4

Hi Folks,

Thanks a million for taking the time to reply and for your advice.

Yes I asked for the claim by email with a signed letter attached and posted the hard copy , that was back in January. Since then despite having asked repeatedly for the file the only response I have received was “it is a manual process and would take time”. At this point I again asked for an estimated date by which I could expect my file and he hasn’t responded as of yet. Do they have a time limit by which they are legally obliged to hand over the information requested? I have sent the same email once a week for the past three weeks and still no response. to any of my queries about my file, the due date for paperwork or getting a copy of my policy. I have since asked my employer for it and received our work version.but will ask again for the master policy as suggested.

There’s also been a lot of messing around with my LTD payments, despite having providing a new void cheque back in January so far its still going into the wrong account and last month it took me 9 days, 4 phone calls and several emails to get the money at all. It. Some unpleasant, untrue throwaway remarks were made by my specialist the last time we spoke on the phone but I emailed the following day refuting his remarks (politely) so there would be some record of it.

I will speak to my medical team about applying for CPP, though my aim is still to to be completely financially independent again, at the moment I don’t know when that will be…

There are several other issues that I won’t bore you with but I feel like I’ve been very patient to date but I’ve just had enough now, it’s is my life they are messing with and all I want to do is use what little energy I do have to get as well as I can, instead I have to keep wasting it fighting with the insurance company and trying to figure out how to protect myself from their cynical games.I just find the whole system so unfairly rigged towards the insurance companies etc .

Apologies for the length of my response and for the mini rant ; )

Once again, thanks Allypops and D.Brannen. I truly appreciate any advice, caution or encouragement .


#5

One of the many traps of an Insurer is to send forms and then deny or stop your benefits because the forms were not received back in a timely way. In the portion of the Master policy that we got it says if requested forms are not returned within 6 months coverage ends.


#6

What they are doing is totally inappropriate. The best thing you can do at this point is to file a complaint with your provincial insurance regulator. If they do cut off your payments, the fact they have treated you this poorly will reflect badly on them if you bring a lawsuit against them. I am very happy to hear that you have maintained your cool…because it is very powerful when we can show how reasonable you have been in contrast to how unprofessional the insurance has been. This is a very power way to frame a case that is going into litigation.


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 reliabile 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.


#7

You should file the complaint with your provincial regulator and request any and all assistance from them.
Your Insurer will take notice. They will get a response for you and the documents sent.
As your Insurer has alerted you to possible IME’s it means they are willing to spend money and looking at your claim closely. Sending in a complaint sends them a message too. I would also add in your complaint how their lack of response is affecting your health or recovery.
If you retain a lawyer then you miss the opportunity to file a complaint as Regulators often refuse to assist represented folks.


#8

Thanks Lori and D. Brannen for your help and advice. I have decided to do as you suggested and have composed a letter to the Superintendent of Insurance which I intend on sending tomorrow. If nothing else it might spur the company on enough to send me my file or at the very least answer my emails and I feel a little less powerless which is always a good thing : ) Thanks again.


#9

Good to hear Jess. It usually takes about 30 days for you to get a response and the documents you requested. You also should not have been in a situation where you had to go to the regulators, but it is wise to have a paper trail of your struggles with your Insurer. You also will have a contact at that department if you need in the future,


#10

Thanks allypops : ).

I’m now a little unsure as to what I’m meant to do in the interim. Do I continue requesting my file and due by dates for the paperwork etc from the claim specialist or do I do nothing until now until I get a response from the SI. According to the website I’ll only be contacted for copies of files if needed and to be told whether or not the file will be closed of if they’ll pursue disciplinary action.They don’t seem to advise you about anything or give you suggestions on how to proceed.


#11

Update:

I’ve just received an email expressing sympathy for my situation and how frustrating the situation is but directing me to go through my Insurance companies complaints process. That in itself seems to be a whole other rigmarole that I’ll now have to try and figure out. The second suggestion was to then report the problem to the Ombudservice for Life and Health Insurers (although from what I can make out, you can only do the second part after the insurance company has finished it’s own internal process which can take up to 90 days) . . .

It seems never ending and I’m so weary of having to spend what limited energy I do have on all of this. However, the other alternative is to do nothing and I just can’t keep over looking all of this.


#13

Wait to you get a response from them again.
As for the due dates of their requested info from you and your Doctor-figure out a date that you can provide it and tell them the date.

You can also let them know that you have reached out for assistance from your Provincial Regulator on the rest.
Let them know it is affecting your health (if it is)

Breathe-you got this.


#14

Hope all is well and you have had an answer for your change of definition date. :slight_smile:


#15

Hey Allypops,
Thanks for checking in, My LTD pyments were due on July 6th this month but money hasn’t come through this week and after several emails to my claim specialist, he’s replied and said it’s because of the COD and that a decision hasn’t been reached.here are lots of other details but I presumed when I heard nothing before June 7th about the COD being denied and received no letter saying that my benefits were being stopped that everything was okay. I had also been told on the phone that my payments would never be stopped without a letter giving me notice. I’m not sure what to do, what if any help the government will be when I can’t pay next months rent, This all seems so unfair and scary, I have no idea what to do now, where to turn for help and I’m not sue if I’m up to fighting this on my own all over again
Jessica


#16

I think there are emergency programs for each province.
If you’re in Otario, ServiceOntario.

What is COD?


#17

COD = Change of Definition


#18

Ouch Jess–sounds like you still have the poor case manager!

The delay is not a good sign and they should not just stop your benefits without warning you in advance!

Are they waiting for information from your Doctors-whats the reason for the delay? Make sure in your emails you add the line about how this is affecting your health.

Hang in there-hit up social assistance, food banks if need be. If it goes on much longer or even now you might want a free consult with a lawyer. It is often easier to get benefits reinstated before you get an out right denial. Lawyers take some of the benefits to pay for their service-but something is better than nothing.


#19

Don’t hesitate to contact us for a free consultation and to order a free copy of my book: A Beginner’s Guide to Disability Insurance Claims in Canada. Chapter 6 explains how to handle your own appeal and has tips for maximizing your chances of success. We also have a webinar replay on how to prepare your own appeal letter.

Many people have their benefits wrongfully stopped at the change of definition and it is possible to get the insurance company to re-start them either voluntarily or by having a court order them to do so.


#20

Hi Folks,

Thanks for responding. I do indeed have the same case manager who I’m sure loves me all the more since I made an offical complaint about him a few months ago because he wouldn’t send me files or respond to my emails. They claimed a letter they sent to me in February asking me for further info also informed me that my benefits would be stopped during the review process. It took 3 emails before he responded to my queries about the missing payment. He claims the delay was waiting for information from my medical team at the PCN (Primary Care Network) has held things up.Whats ridiculous about that is the fact that I have told himself and his colleague repeatedly over the past year that the PCN do not provide any information directly to the insurance company as it all feeds back through to my GP. This matter was discussed yet again with the insurance companies rehab guy at a meeting with my GP in April (when they were trying to force me to go through their rehab program again and my doctor was fighting them on it.) She stated she was the liaison and they were to go through her for information. I had an appointment with her a few days ago and she recalled this herself and said that they haven’t been in touch with her at all for information. So the delay is basically them requesting information from a source they already know won’t provide it???

It all seems ridiculous, legally questionable and morally wrong. We are supposed to be their clients and when we are at our most vulnerable, they harass, confuse and hound you at every turn. Literally , every interaction I have had with them to date has been disingenuous and even worse, detrimental to my health. I’m slowly realising I’m far from alone in having to deal with this stuff. I wish there was a way we could all fight back and sue them for being a health hazard… class action maybe ; )


#21

My husband just filed a lawsuit against his Insurer, the OT, PT and Psychologist that they sent him too.
-no informed consent-lied to him-lied about him
-lied that they had his doctors approval for testing-

then the cover up where they blame him-then had to continue paying him and apologize as they realized we had recorded everything.

So see how it goes. But don’t take it personally-they do it to all the time.

I am ultra Insurance savvy and we still got taken advantage of.