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4 reasons long-term disability claims are rejected, and how to fight back

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When you have an injury or illness that prevents you from working, you should be able to rely on disability insurance through work or a policy you privately purchased. However, insurance companies can and often do deny coverage unfairly for a variety of reasons.

Many times when coverage is denied, people don’t challenge the insurer’s decision. “The vast majority of people are intimidated and believe that because of the amount of resources and money insurance companies have, that it’s a losing proposition to challenge them,” said Sivan Tumarkin, a disability lawyer and founding partner of Samfiru Tumarkin LLP.

The playing field can feel like it’s not an even one. “You have consumers with disability policies who don’t have experience bringing claims for them,” said James K. Fireman, a disability lawyer with Samfiru Tumarkin LLP.

“And on the other side are multi-billion dollar corporations with entire departments dedicated to this one particular task.”

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However, with the right information and preparation you can successfully challenge disability insurance denials. Here are four reasons why claims are denied and why you should challenge them.

Insufficient medical documentation

The insurance company claims that you have not provided them with enough medical documentation to support your disability claim.

This is one of the most common reasons given,” Tumarkin said.

When it comes to medical documentation, the denial letter is packed with daunting details: it looks official, there’s an overwhelming amount of information and almost always you are offered a chance to appeal the decision.

“But their interpretation of the facts generally do not align with the claimant’s interpretation of them. And some people go away out of fear,” said Terry Corcoran, who worked on litigated files for group life and disability claims with major insurance companies for more than 35 years.

This letter alone is considered an intimidation tactic, which can discourage the recipient from moving forward.  “But I’ve worked on cases where we didn’t get any more documentation—we just worked with what we had and the insurance company came back a few months later to settle the case,” says Tumarkin.

 “Total disability”

In November 2018, Sandra Bullock had her long-term disability benefits denied. The Georgetown, Ont.-based woman says her insurance company claimed she was well enough to work again after she took time off to take care of her son with a disability.

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Bullock said she wasn’t well enough to go back to work, adding she was diagnosed with a major depressive disorder, anxiety and recurring migraines. After she retained Samfiru Tumarkin LLP, the firm filed a $5.3 million legal claim against Bullock’s insurance company. Her coverage was restored in February of this year.

Tumarkin notes the term “total disability” is an invented slogan in the industry. “It’s not a legislated term,” he says.

“By using the word ‘total’, they’re making you think it needs to be a catastrophic illness or injury and that’s the furthest thing from the truth.”

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Long-term disability means that you’re unable to do essential parts of your occupation or any occupation for which you are suited by training, education or experience, he said.

‘We have surveillance that shows you’re not disabled’

Often, insurance companies use private investigators to survey people in their everyday lives. “It’s a proverbial tool in the toolbox of an insurance company, but it shouldn’t be the sole reason the insurance company is turning you down,” explained Corcoran.

While the surveillance is unhelpful, the mere concept of surveillance can be nerve-wracking to claimants. “They might send you a letter outlining what the surveillance captured is and it says, ‘Ah ha! We caught you walking your dog,’” Tumarkin said. “But say you have depression. What does it matter that you’re walking your dog?”

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Consider a recent case of Kim Manos, also represented by Sivan Tumarkin of Samfiru Tumarkin LLP.

Manos was accidentally sprayed by a fire extinguisher at a Walmart and later developed reactive airway dysfunction syndrome. This affected everyday life and ability to go to work.

During the trial, surveillance of Manos was presented by a private investigator, but the judge ruled that the video was unhelpful. The surveillance footage was considered brief and it didn’t show Manos wheezing or coughing

 “Unless you’re lying, you have nothing to worry about,” Tumarkin said.

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‘Our medical doctor or consultant doesn’t think you’re disabled’

If a case should come to a court challenge, it may look something like this: Your own physician who has been treating you for years vs. an insurance company’s in-house or hired “expert” who may have spent less than an hour with you.

“Who do you think the judge will believe?” Tumarkin asked. He notes your physician will provide better evidence of your condition than an insurance company’s consultant.

“Again, people are intimidated by this because companies will use that consultant or doctor as a support base to cut you off,” he continued.

So what are your first steps when you receive a denial letter? If you think about appealing it, think again. “Many people appeal it and it will go nowhere but languish in the system,” Fireman said. “Sometimes it’s for years at which point they will likely no longer be entitled to bring a legal claim.” (There’s a two-year limitation period on appeals.)

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Corcoran puts it more succinctly. “At the end of the day, it is the same company with the same objectives that is looking at it again. They’ve already made that decision. You’re knocking at their door asking, “Are you sure?’” he said. “Yes, we’re sure.”

Consider calling a disability lawyer because challenging a claim legally balances this playing field, Tumarkin said. And in most cases you don’t have to pay anything upfront. For example, the disability lawyers at Samfiru Tumarkin LLP only get paid once they recover money for you from the insurance company.

“As soon as a legal claim is filed, the insurance company now has to consider the economic consequences of fighting the claim and potentially losing in court. They will often want to settle.”

Tumarkin offers advice and answers questions about long term disability claims on the Disability Law Show, which airs every weekend on Global TV and Global News Radio.

Looking for more information about disability claims? If your claim has been denied or you have questions about long-term disability claims, Samfiru Tumarkin LLP specializes in disability law in Ontario and British Columbia and can provide a free consultation to discuss your concerns and help enforce your rights over a long-term disability claim.