When an employee has been absent from work during the past few months due to illness or injury, they may be eligible for benefits under the Long Term Disability Plan (LTD) if they are unable to return to full duties. To learn more about Disability Insurance Benefits eligibility and definitial of "Totally Disabled" please ready our article Overview of Disability Insurance Benefits and Eligibility. For more information on disputing denied insurance claims and overview of the legal process involved, please read Disputing Denied Disability Claims, Remedies and Overview of Legal Process.

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Submitting a Claim for Disability Benefits

The benefit booklet (and policy) will describe and set out the details for submitting a claim for disability benefits in the event of an illness or injury. Typically, the employee will notify the employer of the incident and need for a medical leave of absence from work. The employee should request the claim forms from the employer (human resources or plan administrator) or otherwise contact the insurer directly to request the application forms as directed in the handbook.

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Claim forms typically include three separate forms:

1. the employee or plan member form;
2. the employer form; and
3. the plan member's attending physician form.

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Our Disability Lawyers can assist you in completing the plan member form and facilitating the doctor to complete the attending physician form, if these forms have not already been completed and submitted. The benefit booklet and insurance policy will confirm the process for providing Notice or Proof of Claim and the deadlines for submitting a claim.

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What if My Disability Claim is Denied?

Disability insurance is based primarily on contract law principles. The insurance contract (i.e., the policy) sets out the applicable terms and conditions. Each policy is unique and it's important to have an experienced lawyer carefully and thoroughly review each policy for its specific details. If an insurer denies or terminates a claim for benefits or fails to adjudicate a claim in a timely and good faith manner, the insured may have a cause of action for breach of contract and/or breach of the duty of good faith.

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There is no requirement to participate in an insurer's internal appeal process before commencing an action, though it may be wise to do so depending on the circumstances (e.g., if the initial application did not accurately describe the disability and/or did not provide sufficient medical evidence in support of the application and appeal might be warranted). Damages for breach of contract in disability benefit cases is the same as any other breach of contract case: to put the plaintiff in the same position had the contract been performed.

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An action for breach of a disability insurance contract will focus on the denial of benefits or termination of benefits after one has been approved for a period of time. The related damages will center on the disability benefits that the plaintiff would have received had the claim been approved for the extent and duration of the entitlement under the policy.

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Disability Insurer's Duty of Good Faith

An insurer owes a duty of good faith to an insured. Insurance contracts are considered to be contracts of utmost good faith and, accordingly, there is an implied obligation in every insurance contract that the insurer will deal with claims from the insured in good faith. The duty of good faith requires the insurer to act both promptly and fairly when investigating, accessing, and attempting to resolve claims made by an insured person.

A breach of the duty of good faith by an insurer is an independent actionable wrong giving rise to damages.

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Wrongful Dismissals and Disability Benefits

An employment law issue may arise if an employer improperly cuts off access to group health benefits for a dismissed employee who becomes disabled during the common law reasonable notice period. More on this topic in our article Wrongful Dismissals and LTD (Disability) Benefits.

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Our experienced Employment & Disability Group is ready to review your claim in a free consultation, and assist you. Get in touch today.