Long-Term Disability Claim Denied in Ontario: Your Appeal Rights

Why Was My LTD Claim Denied?

• "Own occupation" → "any occupation" definition change — Most policies cover inability to perform your own job for the first 2 years, then switch to any job. Denials often occur at this 24-month mark.
• Insufficient medical evidence — The insurer claims your physician's notes don't adequately document functional limitations.
• Surveillance evidence — Insurers hire investigators. Photos or videos of daily activities may be used to dispute your limitations.
• Independent Medical Examination (IME) — The insurer's chosen doctor frequently finds you capable of work.
• Pre-existing condition exclusion — Policy may exclude conditions that existed before coverage began.

The Internal Appeal Process

When your claim is denied, your first step is a formal internal appeal to the insurer's appeals committee. Submit:

• A letter outlining your grounds of appeal
• Updated medical documentation from your treating physicians
• Functional capacity assessments
• Specialist reports and treatment records
• A rebuttal to the insurer's IME (if applicable)

Insurers typically have 30–90 days to respond to an internal appeal.

Critical Limitation Periods — Do Not Miss These

CPP Disability vs. LTD Benefits

• CPP Disability — federal government program requiring a "severe and prolonged" disability preventing any substantially gainful work.
• Group LTD — private insurance through your employer's benefits plan.
• Individual LTD — privately purchased policy.

After Internal Appeal: External Options

• Arbitration — Some group policies include an arbitration clause for faster, private dispute resolution.
• Superior Court Litigation — Sue for arrears, future benefits, and potentially aggravated/punitive damages for bad faith. Requires a lawyer; a paralegal can assist with pre-litigation steps.