Findlay Personal Injury Lawyers | October 1, 2025 | Personal Injury Cases

When your doctor confirms you cannot work due to illness or injury, yet your insurance company denies your long-term disability (LTD) claim, it can feel like a betrayal of trust. This scenario is unfortunately common in Ontario, leaving many injured and ill individuals wondering how an insurer can dismiss medical evidence from qualified healthcare professionals.

The disconnect between medical support and insurance approval creates stress during an already difficult time. Understanding why this happens and knowing what steps to take can help you fight for the benefits you deserve when facing a denied disability claim.

Key Takeaways

  • Insurance companies may deny claims despite medical support due to policy definitions, documentation gaps, or profit motivations.
  • Common denial reasons include insufficient medical evidence, surveillance findings, and failure to meet specific disability definitions.
  • A systematic approach to appealing a denial includes gathering records, strengthening medical documentation, and following formal appeal procedures.
  • Legal action may be necessary if appeals fail, with specific timelines applying under Ontario law.
  • Working with a disability lawyer improves success rates when challenging insurance claim decisions.

Table of Contents

Can Insurance Deny a Claim?

Insurance companies can and frequently do deny LTD claims, even when you have supporting medical documentation. Insurance companies operate as businesses with financial incentives to limit payouts. They employ teams of adjusters, medical consultants, and lawyers who scrutinize claims for any reason to deny benefits. While they cannot deny claims in bad faith, they have latitude in interpreting policy provisions and medical evidence.

Common Reasons for an LTD Claim Being Denied

These are the most common reasons insurance companies cite when designating LTD claims denied in Ontario:

  • Insufficient Medical Documentation: Your medical records may lack specific details about functional limitations or objective test results.
  • Failure to Meet the Policy’s Definition of Disability: Your condition may not satisfy the specific wording in your insurance policy.
  • Surveillance Evidence Contradicting Your Reported Limitations: Insurers may hire investigators to observe your activities.
  • Social Media Content Suggesting Greater Capability: Posts showing activities inconsistent with claimed limitations.
  • Independent Medical Examination Findings: Insurer-arranged assessments that contradict your doctor’s opinion.
  • Missing Application Deadlines: Failing to file within the policy’s specified timeframe.
  • Pre-Existing Condition Exclusions: Your disability may be linked to a condition that existed before coverage.
  • Failure to Receive Appropriate Treatment: Not following recommended medical care or rehabilitation.
  • Inconsistent Medical Reporting: Contradictions in various medical records.
  • Inability to Prove Disability Beyond “Own Occupation” Period: LTD policies change definitions after 2 years, requiring proving inability to work in any occupation.

How to Appeal a Denied Insurance Claim

When your insurance claim is denied despite medical support, you generally have two options: filing an internal appeal with the insurance company or pursuing legal action. The internal appeal process involves submitting additional medical evidence and addressing the reasons cited in the denial letter.

While this process may seem straightforward, it often does not change the outcome. The same company that denied your claim reviews your appeal, and statistics show relatively low success rates for internal appeals.

For an internal appeal to succeed, you must directly address the insurer’s stated reasons for denial with compelling new evidence. This might include:

  • More detailed medical documentation specifying how your condition limits your ability to work
  • Specialized assessments from medical experts relevant to your condition
  • Functional capacity evaluations quantifying your physical or cognitive limitations
  • Statements from colleagues or employers about observed limitations
  • Daily function journals documenting your symptoms and restrictions

In Ontario, there is typically no legal requirement to exhaust the internal appeal process before filing a lawsuit. Many disability lawyers recommend bypassing the internal appeal in favour of immediate legal action, as internal appeals often delay resolution without improving outcomes.

While internal appeals are an option, filing a legal claim often provides a more effective route to challenge a denied disability claim in Ontario. You should consider legal action when:

  • The insurance company has denied your internal appeal
  • The denial reasons suggest bad faith or an unreasonable interpretation of evidence
  • Your benefits have been terminated after previously being approved
  • The insurer has misrepresented policy provisions or your medical condition
  • You’re approaching the limitation period for filing a lawsuit

In Ontario, the limitation period for bringing legal action against an insurer for disability benefits is typically two years from the date of denial.

If you’re concerned about legal costs, Findlay Law operates on a contingency fee model, so there’s no cost to get started. You pay only when your case is successful, ensuring fair and accessible representation.

What to Do If Your Insurance Claim Was Denied

If your insurance claim is denied despite medical support, follow these steps to protect your rights and build a stronger case:

  1. Review the denial letter. Identify the specific reasons given for denial and note any policy provisions cited.
  2. Request your complete claim file from the insurance company. Under Ontario law, you have the right to access all information in your file, including internal notes and assessments.
  3. Meet with your treating physician. Discuss the reasons for denial and ask if they can provide additional documentation addressing the concerns raised by the insurer.
  4. Consider specialized assessments. Depending on your condition, assessments from specialists, neuropsychologists, or functional capacity evaluators may strengthen your case.
  5. Maintain a detailed symptom journal. Document how your condition affects daily activities, work capabilities, and quality of life.
  6. Consult with a disability lawyer. An experienced lawyer can evaluate your case, advise whether to appeal internally or proceed to litigation, and guide the process.
  7. Be cautious about surveillance. Insurance companies often increase surveillance after denials, so be aware that your activities may be monitored.
  8. Continue appropriate medical treatment. Following your doctor’s recommendations demonstrates commitment to recovery and strengthens your case.

Throughout this process, keep copies of all correspondence with the insurance company, medical appointments, and treatment records. Documentation creates a paper trail that can be invaluable if your case proceeds to litigation.

If your insurance claim has been denied despite medical support, contact Findlay Personal Injury Lawyers for a free consultation. If we take your case, there are no upfront fees. Our team has extensive experience helping Ontario residents challenge wrongful LTD claim denials and secure the benefits they deserve.

FAQs About Denied LTD Claims

How Long Do I Have to Appeal a Denied LTD Claim in Ontario?

Internal appeal deadlines vary by insurance policy, typically ranging from 30 to 90 days after denial. However, the legal limitation period for filing a lawsuit is generally two years from the date your claim was denied. This limitation period may be affected by policy language, so review your policy carefully or consult with a lawyer to confirm the exact deadline in your case.

Should I Continue Seeing My Doctor After My Claim Has Been Denied?

Yes, continuing regular medical treatment after a claim denial is wise for several reasons. First, it ensures your health receives proper attention. Second, ongoing medical documentation strengthens your appeal or legal case by providing continuous evidence of your condition. Finally, failure to pursue recommended treatment could be used by the insurer as grounds to maintain the denial.

What Compensation Can I Receive If My Claim Was Wrongfully Denied?

If your insurance claim was wrongfully denied, you may be entitled to:

  • Retroactive benefits from the date of disability to the present
  • Interest on overdue benefit payments
  • Ongoing monthly benefits if you remain disabled
  • Damages for mental distress in cases of particularly bad faith denials
  • Legal costs and disbursements

The specific compensation depends on your policy terms, the circumstances of the denial, and whether your case settles or proceeds to judgment.

How Is Fault Determined When an Insurance Company Denies a Valid Claim?

When challenging a denied claim, the court examines whether the insurance company had reasonable grounds to deny benefits based on the evidence available at the time. The judge will review medical evidence, policy language, and the insurer’s investigation process to determine if the denial was reasonable or constituted a breach of contract.

In cases where the insurance company acted in bad faith by misrepresenting policy terms, failing to investigate the claim properly, or unreasonably interpreting evidence, additional damages may be awarded. To prove fault, your lawyer will need to demonstrate that your condition meets the policy definition of disability and that the insurer lacked reasonable grounds for denial.