Disability Claims: How to Prove Total Disability

by | Nov 7, 2017 | Disability Claims

Disability Claims: How to Prove Total Disability

Claims for long-term disability (LTD) are complicated legal matters that rely on facts, expert medical opinion and a claimant’s ability to prove the extent of their disability. A successful claim must also prove total disability.

What is Total Disability?

LTD claims are often denied because insurer has concluded that the applicant has no suffered a total disability. To insurance providers, the general rule of total disability in a LTD context is that one is unable to fulfil the functions of any job based on training, education and experience. However, each policy of insurance is unique and should be reviewed carefully by experienced counsel.

The Tests for Total Disability

Every LTD claim is different and dependent on the terms of the policy. There are tests that each claimant must pass to satisfy the insurance providers and lay the foundation for a successful LTD claim.

The “Own Occupation Test” refers to the claimant having proven that—due to their disability—they were unable to perform the requirements of their occupation, the one held at the time of the injury, for a prolonged period. This test is not designed to prove that the claimant is unable to perform any job. It is designed to prove that the claimant could not perform in their actual job.

The “Any Occupation Test” goes a step beyond the “own occupation” test. Once the period for the Own Occupation test ends, the claimant must prove that they cannot perform in any relevant occupation, thus, proving total disability. The insurance provider must be convinced that the disabled person can not reasonably perform the essential duties of any occupation. While more subjective then the Own Occupation Test, the Any Occupation Test uses jobs that the claimant is suited for based on their education, experience and training.

The test is defined differently for every policy and polices of insurance can have combinations of test during different periods of time.

How to Prove Total Disability

If someone has suffered injuries or mental anguish so pervasive that it undermines their ability to perform at their place of employment, then they should seek disability to cover their lost income. Insurance providers do not just blindly approve claims. Instead, they make it quite difficult and place the pressure on the policy holder to prove the veracity of their disability. Once proven, the insurance provider still needs to be convinced of the extent of the disability.

Proving total disability is a process that typically includes your doctor, your insurance provider, and depending on the disability, one or more medical specialists like a psychologist. For a myriad of reasons, an insurance provider may deny a disability benefit but that doesn’t mean that your claim is done. A claimant can appeal a decision and present their claim to the Ontario Superior Court of Justice.

CPP Disability Claims

In some instances, insurance providers will make claimants apply for CPP disability benefits.Depending on the type of policy the claimant has been paying for, CPP disability benefits can be helpful. More expensive policies have clauses that don’t include CPP deductions. There are situations where this is more beneficial to the insurance company so make sure you understand the requirements of your policy. Of course, the insured has the option to pay more for better coverage.

Per the Canada Pension Act, which governs CPP disability benefits, a person is deemed disabled if they meet several requirements, which include but are not limited to:

  • If they are determined to have a severe and prolonged mental or physical disability.
  • A disability is severe only if the person is made incapable of any substantially gainful occupation.
  • A disability is prolonged only if it is determined in prescribed manner that the disability is likely to be long, continued and of indefinite duration, or is likely to result in death.

The best advice is to speak with both your insurance provider and a personal injury lawyer who can help you understand all the terms and clauses, ensuring that nothing is overlooked.

Our Personal Injury Lawyers Can Help

The dedicated team of personal injury lawyers at Mackesy Smye can help prepare a proper insurance claim or appeal. We have the experience and expertise to make sure our clients have the strongest case possible, contact us today to discuss your situation.

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