So hard to find information to decide how to present LTD claim

I’ve been reading everything I can find to clarify parts of the DI contract that are ambiguous for my personal situation, and so that I can have the best chance at getting approved.

It’s almost impossible to find out how the insurance companies assess claims or apply specific clauses (like the exclusions for pre-existing illness - its unclear what similar illness means and who determines this. How do I answer that question in the form. How would I be able to say they are similar!?).

I went on sick leave for 17 weeks and received EI benefits. I did not submit a DI claim I started a progressive return to work. I later realized that I would have to submit a claim after all to get paid while I was returning to work. My 4th week back, I had to go back on sick leave again. I had not yet submitted the claim.

The diagnosis I got previously was potentially not eligible (generalized anxiety : I have been treated for depression w/ anxiety symptoms) But the I was very recently diagnosed with a different disorder, which is what my disability claim will be based on.

Is that new diagnosis also valid for the period before I returned to work? It was present, just not diagnosed yet.

Do I submit a single claim for the whole period?
Do I submit 2 separate claims?
Do I submit a claim only for the first leave and wait to add the current disability?

Do I have to wait another 13 weeks?

Im stuck, unable to get the medical form filled out until I figure out the best approach.

1 Like

If you mean if one claim is a continuation of a previous claim then at least with my insurance company I think it is any claim within a few months (6 comes to mind). I think there is a post on this site from David (I might have asked something similar).
I was off work, submitted a claim, returned to work briefly, submitted a claim. The insurance company told me the 2nd claim was a continuation of the 1st claim because it was within x months.
I have no idea about backdating a claim but you were on EI Sick Benefits so the insurance company will hopefully not make you wait another 13 weeks.
I would submit the claim and talk to the insurance company.
You can always talk to a lawyer if they won’t consider it 1 claim.
I would say they are the same illness that caused your disability both times (if you believe that).
I would just submit 1 claim if your doctor says both times had the same underlying cause.
Good luck.

1 Like

Oh, thank you so much for taking the time to read and reply. That makes a lot of sense to me. I will submit one claim for both leaves and hope I don’t need to wait 13 weeks.

Last time I tried to get some information, I didn’t get anything from the person I spoke to but I think I’m going to call and ask about this:

How would I know or determine if it was caused indirectly or was similar?


Payment is not made for

1. a Total Disability due to or resulting directly or indirectly from an Illness which existed on or before on or before the commencement date of the Employee’s insurance…


…Have you ever had the same or similar illness or injury?


1 Like

Maybe your doctor has an opinion.

Is it likely the recent disorder existed before the employment but went undiagnosed?
Could the recent diagnosis have resulted from the generalized anxiety you had before?

I don’t have that pre-existing clause.

That “payment is not made…” clause seems like it’s going to be a problem.
It might be ok though. :slight_smile:
Do the best you can and if they deny it, talk to a lawyer.

Read this stuff:





Yes, there is a pre-existing clause. I was not quite at the 1 year mark when I went on leave. The most recent disorder did not exist before my employment but I am worried the insurance will try to say that both recent diagnosed disorders resulted from the pre-existing major depression (diagnosed a few years ago but stable for quite a while). However how can would they prove this?

I was hoping to have it all figured out before sending my GP the form to fill out but I think you are right and I will have to discuss it with her. The problem is that I’m completely over extended financially at this point, so I really have to submit as soon as I can. But I know that if I go too fast and don’t think this through, I might just set myself up for denial.

Unfortunately my next appointment is still 2 weeks away, my GP only works 2 days a week and the secretary totally shut me down when I asked if I could see the doctor this week. I think I will try again tomorrow and say it’s an emergency. Maybe I’ll get a more compassionate receptionist. I’m seeing a specialist for a complete evaluation next Tuesday so maybe she’ll be able to fill a form as well.

It’s so interesting. After I wrote my last post I decided to add more information in my own words, to include with the form and other documents. Then I checked my emails and saw this! Perfect timing. This is unbelievably useful right now,

2 Likes

You can’t control that.
They probably can’t prove it.
Worst case they would say that and deny you and make you sue.
They also might not do that and approve it. :slight_smile:
Try to answer questions that you think they might have but also get the application done.
You haven’t seen the specialist yet?
It may be better to get them to fill out the medical forms.
At least provide evidence you saw a specialist.
Good luck.

1 Like

Hi, Welcome to the Forum. I am glad you liked my article on the Secret to Winning a Disability Claim! I consider this to be one of the most important blog articles I have ever written.

To answer some of your questions, the pre-existing disability clauses typically only apply if you have been enrolled in the group plan for less than 1 year (sometimes 2 years). Sounds like that does apply, so in a situation like yours the insurer will always look into whether your reason for disability would fall under the pre-ex clause.

You are dealing with one continuous period of disability. Usually, that will only be broken if you return to work full time for 6 months or more. Emphasis on full time. If you don’t get to full time or go off again within a period of time (usually 6 months) then it is considered the same claim.

Good luck with your claim.


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 reliable 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.

Hi, thanks for the information. Sorry, long post again…

I finally submitted my claim and subsequently received a letter from the insurance company saying they need to investigate more in regards to the pre existing exclusion clause. I went on disability shortly before the 1 year mark.

They requested doctor’s notes dating back 1 year prior to my hiring date. There is little more information in the added documents, nor did my doctor have much to add to their questionnaire. She was actually really baffled and annoyed at the redundant questions. Another fee I can’t afford.

At this point, I’ve been without income for several months and am in a really bad situation financially. I’ve asked the insurance company what the the new eta is and what I should expect but haven’t heard back yet.

From what I understand, the only time frame they commit to is the 10 business days to respond to the initial claim. I’m assuming they can and do take as long as they want once they determine they need to investigate more.

Is there anything I can or should be doing? Should I put pressure and phone the person who is assessing my claim?

What do I do now?

Also, am I including too many details on an online public forum?

Apply for EI-Sickness benefits in the mean time.
Apply for the DTC (Disability Tax Credit).
Apply for social assistance.
Apply for CPP-D.

The insurance company will be slow.

I don’t know.
The insurance company will use anything against you so maybe don’t post as much.
Maybe wait for a “yeay or nay” from the insurance company.
I’m sure @David_Brannen has an opinion.

I have more questions… Sorry! Btw I did remove some of the personal information from my previous post. I don’t have anything to hide but probably best to avoid details.

My first question is about requesting clarification and clear definitions of terms used by the insurance company that are ridiculously vague, broad and meaningless.

I sent them a follow up email after faxing the latest medical documents they requested and added a brief message with specific questions about terminology in a letter they sent me. (I always fax and email the documents myself, which is good because I caught an error in the initial questionnaire : an entire page was missing. I also want to know what my doctor is providing and what the insurer is requesting!)

Do you think they will answer? Can I insist if they won’t provide the info? How can I or my doctor answer when the question isn’t clear? I asked for definition and examples. It seems like a reasonable request.

How would I go about submitting a claim in order to be reimbursed for the doctor’s fees I had to pay? Directly to the case worker (email) or through my health benefits insurance claims?

I had to pay twice within less than 2 months and the latest request resulted in about at most 10% new information. They literally asked the same questions that my doctor already answered in the initial questionnaire and the file notes were the same ones previously provided with the addition of maybe 5 pages.

This is so frustrating. I can’t believe we have to go through this process.

That seems common and may be meant to “trip you up”.
Don’t answer in absolute terms.

Maybe.
It took mine 3 months to answer a simple question and I had to convince them it didn’t mean I could work.

I doubt it but don’t know.
Answer the best you can.

I don’t know.
Can you submit claims online?
Ask them.

I had to pay for everything to support my claim.
It was in my policy that I have to pay.
I think if the insurance company requests a report directly from a doctor, they pay.
I think that is only on an approved claim.

Wait for their decision and if there is an denial, and any mention of a pre-existing condition as a reason, then you should seek legal advice immediately. Any case with the possibility of a pre-existing condition exclusion needs to be handled very very carefully because it is easy for you or your doctor to make inadvertent statements that help the insurer prove their case against you.


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 reliable 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.