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An insurer must act in utmost good faith to provide peace of mind to the insured. This is why an internal appeal can be made should a long-term disability (LTD) claim be refused.

What is an LTD Appeal? An LTD internal appeal is a reconsideration of your LTD claim that has been previously denied by the insurer. By appealing internally, you are asking the insurer to take another look at your claim. These claims are reviewed by employees of the insurance company—called claims adjusters. Often, the insurer will have a new adjuster review your claim on an internal appeal. They may also have a medical consultant review your claim. In most cases, you have two or three internal appeals available to you. At each step, you must prove to the claims adjuster why your LTD claim should be accepted. Insurers usually provide a timeline in which to request an internal appeal. This timeline will be set out in their denial letter. An effective way to get guidance on how you can improve your application throughout the appeal process is by way of your denial letter. This letter will often outline the reasons why you were denied LTD benefits. This information can be a great tool for you to provide additional information to help reduce the concerns raised by the insurer. Insurance policies will often place the burden of proving the LTD claim on the insured. Documents that may assist you in proving your claim could include more comprehensive or up-to-date medical records, new medical tests/imaging or further employment records. A written report from your treating doctor providing a favourable opinion as to why your medical condition prevents you from returning to work is often very helpful. Your claims adjuster has an ongoing responsibility to adjust the claim based on the supporting medical evidence before them. This means they must decide LTD claims based on the medical evidence at the time. By providing documentation that refutes the reasons outlined in the denial letter, you have a much better shot at succeeding in your internal LTD appeals. The Drawbacks of LTD Appeals One of the major pitfalls in proceeding with internal appeals is that it can be a long, drawn-out process that may delay payments to you. The appeals may potentially take months to process. To reduce this delay, it is important to provide the insurer with all the necessary paperwork with your written appeal request to avoid unnecessary hardships. Please keep in mind that if you plan on appealing more than once, it is of the utmost importance that you are presenting new and important evidence after every appeal. Another drawback to the LTD appeal process is that claims adjusters often lack the medical credentials to make an informed decision regarding your case. Since the minimum requirement to be a claims adjuster is a high school diploma, they might miss key medical concepts and terms related to your case. It is necessary for you or your lawyer to determine the claims adjuster’s background and experience, including their résumé and job description to better understand their actual capabilities. Furthermore, since claims adjusters work for insurance companies, they will not have your best interests in mind. The reality is that they will oftentimes continue to side with the insurer upon appeal while also wasting more of your time via the delay. This is why very few internal LTD appeals are actually successful. Civil Litigation with LTD Claims Should your LTD claim and appeal be unsuccessful, you could be entitled to compensation through civil litigation. Otherwise known as a civil lawsuit, a Statement of Claim must be filed with the Court within 24 months of your denial letter. This should always be kept in mind when appealing internally. You do not want your window to close while in the process of appealing internally with the insurer. The civil litigation route will bring your case before an impartial judge or jury who will hear your case and make a decision based on the facts before them. In our experience, this has proven to succeed far more often than internal LTD appeals. What Route Should You Go? Both options are available to you. Internal appeals are a simpler way to get your LTD claim reconsidered by your insurer. Depending on the specifics of the denial letter, a few medical documents can swing the claim in your favour. However, if there are more complex factors involved within your LTD claim, the internal appeal process could be a waste of your time. If your internal appeal is unsuccessful, you still have the option of proceeding with civil litigation. You should consult an LTD lawyer to assist you if you wish to proceed with civil litigation. Fighting your LTD claim through civil litigation is a complicated process. With the help of an LTD lawyer at Littlejohn Barristers, your case can be fought strategically outside of the confinements of an internal appeal. The LTD lawyers at Littlejohn Barristers will assist you by answering all your questions regarding your long-term disability benefits claim. Littlejohn Barristers has a team of lawyers who are experts in disability insurance and will review your case with you. There is no up-front fee or cost involved in any initial meeting. If you require a Barrie LTD lawyer with extensive experience with LTD claims, please do not hesitate to contact Littlejohn Barristers at (705) 725-7355.


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