An illness or injury can make it difficult to continue working and earning your regular income. In some cases, the condition may keep you away from work for weeks, months, or even longer. Disability benefits can provide financial support during that time.
There are several types of disability claims in Canada. The claim you need will depend on your insurance coverage, employment, medical condition, and the benefit program involved.
It is also important to understand the difference between private disability insurance and government benefits. Each has its own rules, application process, and definition of disability.
What Is a Disability Claim?
A disability claim is a request for benefits after an illness, injury, or medical condition affects your ability to work.
Disability coverage can come from several sources, including:
- Employer-sponsored disability insurance
- Private disability insurance
- Short-term disability plans
- Long-term disability insurance
- Canada Pension Plan Disability benefits
- Employment Insurance sickness benefits
- Provincial disability programs
The rules are not the same for every type of benefit. An insurance policy might include a waiting period, exclusions, medical requirements, and a specific definition of disability. These details can affect whether your claim is approved and how much you receive.
Common Types of Disability Claims in Canada
1. Long-Term Disability Claims
Long-term disability (LTD) insurance helps replace part of your income when an illness or injury prevents you from working for an extended period.
Many employees have LTD coverage through a workplace benefits plan. Individual LTD policies are also available for people who purchase disability insurance directly.
The amount of your LTD benefit and the length of time you can receive it are determined by your policy.
The definition of disability is another important part of an LTD claim. At the beginning of a claim, the insurer may look at whether you can perform your regular occupation. Later, the policy may require you to show that you cannot work in another occupation that fits your education, training, or experience.
This change in the disability test can lead to disputes when an insurer decides to stop benefits.
Virk Personal Injury Law represents clients dealing with long-term disability claims, including disputes involving denied or terminated benefits.
2. Short-Term Disability Claims
Short-term disability (STD) benefits provide temporary income when an illness or injury prevents you from working.
Many employees receive STD coverage through their employer. Some people also have short-term disability coverage under an individual insurance policy.
The terms vary from one plan to another. The policy will normally set out the waiting period, benefit amount, medical requirements, and maximum period for receiving payments.
For some workers, an STD claim is the first step in a longer disability claim. If the medical condition continues, the person may eventually need to apply for long-term disability benefits.
3. CPP Disability Claims
Canada Pension Plan Disability (CPP-D) benefits are government benefits for people who meet the CPP contribution requirements and have a severe and prolonged disability that prevents them from working regularly.
CPP-D is separate from private disability insurance. The eligibility requirements and application process are different from those used by an insurance company.
A person can sometimes receive CPP disability benefits while also receiving LTD benefits. However, an LTD policy may allow the insurer to reduce the LTD payment by the amount received through CPP-D.
Anyone receiving both benefits should therefore review the terms of their LTD policy carefully.
4. Disability Insurance Claims Through an Employer
Disability coverage is included in many employee benefit packages.
A workplace plan may provide both short-term and long-term disability coverage. The exact benefits are set out in the group insurance policy provided by the employer.
Coverage can vary significantly between employers. One workplace may have different benefit amounts, waiting periods, or eligibility requirements from another.
When an insurer denies a claim, it may rely on the policy wording, medical evidence, job duties, or its interpretation of the definition of disability.
The actual insurance policy should be reviewed before reaching a conclusion about whether a claim is covered.
5. Individual Disability Insurance Claims
Disability insurance does not always come through an employer. Individuals can purchase their own coverage directly from an insurance company or through an insurance broker.
An individual disability policy can have different terms from a group benefits plan. It may contain specific provisions dealing with the definition of disability, exclusions, waiting periods, benefit amounts, and the length of coverage.
The wording of the policy becomes particularly important when an insurer disputes a claim.
Virk Personal Injury Law represents clients involved in disputes over individual disability policies as well as group long-term disability coverage.
Common Medical Conditions Behind Disability Claims
Disability claims can result from many different illnesses and injuries. Some conditions affect a person’s physical ability to work, while others affect concentration, memory, mood, or day-to-day functioning.
Conditions commonly involved in disability claims include:
- Back and spinal conditions
- Chronic pain
- Arthritis
- Fibromyalgia
- Cancer
- Neurological conditions
- Multiple sclerosis
- Brain injuries
- Depression
- Anxiety
- Other mental health conditions
- Cardiovascular conditions
- Serious injuries
- Chronic illnesses
A medical diagnosis does not automatically qualify someone for disability benefits.
The insurer or benefit provider will look at how the condition affects the person’s ability to work. Medical restrictions, symptoms, treatment, job duties, and the applicable definition of disability can all form part of that assessment.
What Does an Insurance Company Look At?
An insurance company will usually review several types of information when assessing a disability claim.
This can include:
- Medical records
- Reports from doctors and specialists
- Symptoms and functional limitations
- Occupation and job duties
- Work history
- Treatment history
- Medications
- Medical assessments
- Surveillance or other evidence
- The wording of the insurance policy
The insurer may ask for additional medical records or request that you attend an assessment.
Your medical records should clearly describe not only your diagnosis but also how your condition affects your ability to function. Information about your symptoms, restrictions, treatment, and ability to perform your job can be particularly important.
Does a Medical Diagnosis Automatically Qualify You for Disability Benefits?
No. Having a particular diagnosis does not automatically mean that a disability claim will be approved.
Two people can have the same medical condition and experience very different limitations. One person might continue working, while another might be unable to perform the duties of their occupation.
For an insurance claim, the focus is often on the effect of the condition rather than the diagnosis alone. The insurer will consider whether your medical limitations meet the definition of disability contained in your policy.
This is why medical evidence should explain how your condition affects your ability to work and carry out your regular activities.
What Happens If a Disability Claim Is Denied?
A denied disability claim can create serious financial pressure, especially when you are already unable to work.
The insurer should provide the reason for its decision. A denial might involve a disagreement about your medical evidence, the definition of disability, an exclusion in the policy, or another issue relating to your coverage.
Do not assume that the insurer’s decision is the final word.
Keep your denial letter, insurance policy, medical records, claim forms, and correspondence with the insurer. Check whether there are deadlines for an appeal or legal action.
If you believe your claim was wrongly denied, a disability lawyer can review the decision and explain the options available to you.
Related: Insurance Claim Denial Lawyers
Can You Receive More Than One Disability Benefit?
In some situations, a person can qualify for more than one disability benefit.
For example, someone receiving LTD benefits might also qualify for CPP disability benefits.
The two benefits are not always paid in full at the same time. An LTD policy may contain an offset provision that allows the insurer to reduce its payment after CPP-D benefits begin.
Other benefits can have their own rules about how payments interact. The answer will depend on the specific policy and benefit programs involved.
How Long Do Disability Benefits Last?
The length of disability benefits depends on the type of coverage you have.
Short-term disability benefits generally cover a limited period. Long-term disability benefits can continue for several years or until a specified age, depending on the policy.
An insurer can also reassess an LTD claim during the benefit period. In some policies, the definition of disability changes after the initial period of coverage.
For example, you might initially qualify because you cannot perform your own occupation. Later, the insurer may assess whether you can perform another occupation that matches your background and experience.
When Should You Speak With a Disability Lawyer?
Legal advice can be useful when a disability claim becomes disputed or complicated.
You may want to speak with a disability lawyer if:
- Your disability claim has been denied
- Your LTD benefits have been terminated
- The insurer says you are able to return to work
- Your medical condition is being questioned
- You are asked to attend an insurer-arranged medical assessment
- The insurer raises concerns about your medical history
- You are accused of providing inaccurate information
- You do not understand the definition of disability in your policy
- You are concerned about an appeal or legal deadline
You do not need to wait until a lawsuit has started before getting legal advice. Understanding your rights early can help you decide how to handle the claim
Disability Claims at Virk Personal Injury Law
A disability claim affects more than your ability to earn an income. When you cannot work, you may also have medical expenses, household bills, and other financial responsibilities to manage.
Virk Personal Injury Law represents clients dealing with disability insurance disputes, including long-term disability claims, short-term disability claims, individual disability policies, group insurance policies, and CPP disability matters.
If your disability benefits have been denied or terminated, our lawyers can review your situation and explain the legal options available to you.
Frequently Asked Questions
What is the most common type of disability claim in Canada?
Long-term disability claims are common among employees who have disability coverage through their workplace benefits. Individual disability insurance can also provide LTD coverage.
The type of claim available to you will depend on your insurance coverage and circumstances.
What medical conditions qualify for disability benefits in Canada?
There is no single list of medical conditions that automatically qualifies a person for every disability benefit.
Eligibility depends on the particular insurance policy or government program. The effect of your condition on your ability to work is also an important part of the assessment.
Can I receive CPP disability and LTD benefits?
Yes, it is possible to receive both benefits. However, an LTD policy may allow the insurer to deduct CPP disability payments from your LTD benefits.
Check the terms of your policy to understand how the two benefits interact.
What should I do if my disability claim is denied?
Start by reviewing the denial letter and the reasons given by the insurer. Keep copies of your policy, medical records, claim documents, and correspondence.
Pay close attention to any deadlines that apply. If you disagree with the decision, consider speaking with a disability lawyer before deciding what to do next.
Can an insurer deny a claim because of a pre-existing condition?
A pre-existing condition can affect coverage in some circumstances. The answer depends on the wording of the insurance policy and the facts surrounding your claim.
The insurer’s decision should be reviewed against the actual terms of your policy.
How long does a disability claim take?
There is no fixed timeframe for every disability claim.
The process can depend on the type of benefit, the medical information available, the insurer or government program involved, and whether there is a dispute over your eligibility.
Speak With Virk Personal Injury Law About Your Disability Claim
Being unable to work because of an illness or injury can create significant financial and personal challenges. If your disability claim has been denied or your benefits have been stopped, it is important to understand your rights before deciding what to do next.
Virk Personal Injury Law helps clients deal with disability insurance disputes and denied disability claims.
Contact Virk Personal Injury Law to discuss your disability claim