If your long term disability (LTD) claim was denied or cut off, you’re not alone. The good news is that many denials follow predictable patterns. Here are 10 of the most common reasons why LTD claims in Ontario are refused and how to improve your chances on appeal or litigation.
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You don’t meet the policy’s test of “total disability”
For the first 24 months, most group policies ask whether you can perform the essential duties of your job. After that, the definition usually changes to whether you can perform any occupation you’re reasonably suited for by education, training or experience. Many claims are cut off at this “change of definition.”
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Not enough medical evidence
A denial will sometimes indicate that your medical records are incomplete, or that the doctor didn’t explain functional limits (e.g., how long you can sit/stand, what symptoms prevent you from working, etc.). Mental health and pain cases are especially vulnerable when physician chart notes are brief.
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Pre existing condition clause
Group LTD commonly excludes disabilities that occur within a set window following the beginning of your coverage. That may also include conditions you were treated for during a “look back period”, a designated timeframe before the beginning of your coverage that your insurance company might use to determine your eligibility for coverage. The wording varies by plan.
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Missed deadlines or waiting period rules
LTD has an elimination (waiting) period, that varies according to your plan. Policies also impose timelines for giving notice and proof of claim. Late, missing, or inconsistent paperwork is a frequent reason for denial.
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Not following “reasonable” treatment
Most policies require ongoing care from an appropriate physician and participation in recommended treatment or rehabilitation. Gaps in care or declining therapy without a good reason may be cited as a reason from the insurance company to stop providing benefits.
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Problems with insurer ordered examinations (IMEs)
If you refuse or miss an IME — or an IME doctor suggests that you are capable of working — the insurer may deny or terminate benefits. You can’t ignore an IME, but you can prepare and respond.
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Surveillance or social media contradictions
Insurers may review public posts or hire investigators. Clips taken out of context (a “good day,” a brief lift, a short outing) are routinely used to challenge credibility.
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The insurer says you can do “other suitable work”
Even if your exact job is off the table, an insurer may argue you can perform other occupations (especially after the 24 month mark) and deny on that basis.
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Eligibility or coverage gaps
Denials can stem from not being an “eligible employee,” not being “actively at work” when coverage should have started, a lapse in premiums, or an exclusion cause.
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Errors, omissions, or misrepresentation in the insurance paperwork
Material misstatements (especially within the first two years of coverage) can lead an insurer to void coverage or deny benefits. Fraud is always a problem; innocent mistakes can also be argued.
What To Do If You’re Denied:
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Read the denial letter and your policy—together
Identify the exact definition being applied, what evidence the insurer says is missing, and every deadline.
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Fill the evidence gap, not just the form
Ask your healthcare providers to write narrative reports that connect the dots: diagnosis, symptoms, functional limits, how those limits prevent job duties, and prognosis. For mental health and pain conditions, detailed function focused reporting is especially important.
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Track your symptoms and function
A simple daily log (pain levels, sleep, flares, meds, side effects, activity tolerance) helps your doctor document restrictions and gives context to any “good day” footage.
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Stay engaged in treatment
Attend appointments, follow reasonable recommendations, and document why you can’t pursue a treatment (cost, side effects, clinical advice). If you’ve plateaued, ask your doctor to say so. That includes preparing well for IMEs. Bring a concise list of symptoms, limitations, and medications. Be truthful and consistent; don’t “perform.” Afterward, write a short memo of what happened and share it with your lawyer.
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Be mindful of social media
Assume insurers will look. Avoid posting anything that could be misconstrued. Privacy settings help but aren’t a shield.
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Keep an eye on timelines
Insurance company appeals typically have tight timelines. Separately, Ontario lawsuits are usually subject to a two year limitation that often starts when benefits are clearly denied or terminated. Get legal advice early so you don’t miss the window.
If you’re thinking of making a disability claim or you’ve been denied, you don’t have to deal with it alone. Blackburn’s team has decades of experience dealing with these sorts of cases, and we’ll advocate to get you the help you deserve. Contact us today for a free consultation.
* Please note that the information in this article is not intended as legal advice, but rather as a general overview on the subject. If you are seeking legal advice, please consult with a lawyer.
