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Opens in new windowFor Ontarians facing severe or long-lasting health issues that prevent them from working, long-term disability (LTD) benefits are essential. These benefits provide crucial financial support by helping to maintain stability during a challenging time.
To help you navigate this complex process, we spoke with Sivan Tumarkin, national co-managing partner at Samfiru Tumarkin LLP. He shares his insights on LTD benefits, eligibility, the differences between short-term and long-term disability, the steps to apply, and how to get legal support if your claim is denied.
What are LTD benefits, and how are they different from short-term disability benefits?
LTD benefits provide income support for individuals unable to work due to long-term health conditions or injuries. These benefits typically replace a portion of the recipient’s income, helping to cover essential expenses during a prolonged disability. Designed for severe or extended disabilities, LTD benefits generally offer financial support until recovery or retirement age – usually at a lower percentage of pre-disability earnings. In Ontario, LTD benefits are accessible through employer-provided insurance plans or private insurance.
Short-term disability benefits, on the other hand, cover temporary disabilities and offer faster financial support, often replacing up to 80 per cent of your income for a few weeks or months.
LTD claims in Ontario require a more detailed application process, including comprehensive medical documentation, and they usually involve a longer waiting period before benefits start.
1. What are the eligibility requirements?
At a high level, these are the basic eligibility requirements for LTD benefits in Ontario:
- Be an Ontario resident.
- Be covered by an employer-sponsored insurance plan or a private policy.
- Have worked for your employer for the qualifying period defined by your insurance policy.
- Be unable to work due to a long-term injury, illness or medical condition.
The requirements of every LTD policy can vary. Review your policy carefully to understand the qualifications and how your condition aligns with the insurer’s definitions of disability.
When evaluating the limitations of your long-term injury, illness or medical condition, support from your doctor or health care team is critical. According to Tumarkin, “You need people on your side who are actively treating you, like a family doctor, psychologist, psychotherapist, chronic pain specialist, or physiotherapist. Whoever is treating you should confirm that you’re unable to work and can’t complete the tasks of your job. With this support, your insurance company should approve your claim.”
2. How do I apply for LTD benefits in Ontario?
Applying for LTD benefits can be an involved process that requires both preparation and patience. Follow these steps to increase your chances of success:
- Obtain a diagnosis: Consult your doctor to establish a clear diagnosis. This documentation is critical for supporting your claim.
- Review your policy: Make a checklist of all the documents and info required to qualify based on your LTD policy’s terms.
- Gather medical records: Collect thorough medical records from your doctor, including your diagnosis, symptoms, treatment plans and how your condition affects daily functioning.
- Complete application forms: Fill out your insurance provider’s application forms accurately and completely, demonstrating how your condition impacts your ability to work.
- Submit your application: Provide the completed forms, medical records, statement from your doctor, and any other required documentation to your insurance provider.
- Follow up: Regularly check on the progress of your application and be ready to provide additional information if requested by the insurance company.
- Understand the decision: If your application is approved, carefully review the terms, amount, and duration of your benefits. If denied, avoid rushing to file an appeal without first seeking legal advice. Contact the Ontario LTD lawyers at Samfiru Tumarkin LLP to better understand your options. Their experienced team can assess your case and recommend the best course of action to challenge the denial effectively.
Speaking on why insurance appeals often fail, Tumarkin explains: “Appeals fail because they’re part of the insurance company’s internal process - the same company that already denied your claim. If they’ve denied you once, what incentive do they have to change their mind? In my experience, when insurers encourage you to appeal, it’s because they want to keep you in their process and delay the chance for you to get real help. That’s why it’s crucial to speak to a lawyer first, so you can explore your actual options and take the right steps from the start.”
3. How much do LTD benefits pay and how long do they last?
In Ontario, LTD benefits typically cover between 60 and 80 per cent of your gross income before the disability. The exact amount depends on several factors, including your insurance policy, salary, disability severity and other individual circumstances. Many LTD plans also have a monthly cap that limits the total benefit amount, regardless of income.
If you’re receiving income from other sources - such as Canada Pension Plan (CPP) disability benefits, WSIB payments, or severance pay, your LTD payments may be reduced. These reductions, called offsets, vary depending on the terms of your insurance policy.
LTD benefits usually last until you are medically cleared to return to work or until the policy’s term expires. For most plans, this is at age 65, but some policies offer coverage for a fixed term, such as five or 10 years. Reviewing your policy’s terms carefully will clarify the expected duration of benefits.
4. What do I do if my LTD claim is denied or cut off?
Even if you meet all the eligibility requirements, LTD claims are frequently denied. But don’t lose hope! Insurers often argue that a claimant isn’t “totally disabled,” lacks sufficient medical evidence, or has pre-existing conditions. Other common reasons for denial include filing a claim late or failing to follow your doctor’s prescribed treatment plan.
If your claim is denied, taking immediate action is crucial. Contact Samfiru Tumarkin LLP - the experienced team is well-versed in handling denied LTD claims in Ontario. They can provide strategic advice tailored to your situation, guiding you through the complexities of your case.
Your insurance company may encourage you to appeal their decision. However, this process is often time-consuming and unproductive, as the same insurer that denied the claim is responsible for reviewing the appeal. An alternative is to file a legal claim for compensation, which can be a more effective approach than pursuing repeated appeals. With extensive experience in denied LTD claims, Samfiru Tumarkin LLP can assess whether filing a legal claim is the best step for your case.
As Tumarkin explains, “The last thing insurance companies want is for you to contact a lawyer. Clients have even told us that their insurer specifically advised them not to, which they’re never supposed to say. They want to keep the process in their own system. Speak with us to get unbiased, expert advice on your rights.”
5. How Samfiru Tumarkin LLP can support you
Samfiru Tumarkin LLP has extensive experience and a proven track record of success in handling long-term disability cases across Ontario and Canada. The firm’s disability lawyers, including some who previously worked within insurance companies, understand the tactics insurers use to deny claims and can effectively counter them.
Their approach begins with a thorough review of the reasons for denial, ensuring clients understand the timelines and requirements for appeals or legal actions. By building a strong case, gathering comprehensive medical evidence, and advocating for clients’ rights, they have secured benefits or compensation for thousands of Canadians.
The results speak for themselves. Beyond their thousands of positive Google reviews and strong reputation, the firm has delivered tangible success for clients. For example, Samfiru Tumarkin LLP fought to have a client’s LTD benefits reinstated after Sun Life wrongfully denied her claim - a case that garnered media attention from Global News. In the end, the client achieved a legal victory and the benefits she rightfully deserved.
In another case, Samfiru Tumarkin LLP advocated for a Barrie teacher who suffered a severe brain injury during an assault by a student and was unable to return to work. When OTIP initially denied her LTD benefits, the firm stepped in to handle her case. Their efforts resulted in $113,000 in compensation for the teacher, along with additional benefits, providing her with much-needed financial security during a difficult time.
Recognized as Canada’s leading disability law firm, Samfiru Tumarkin LLP provides a range of resources to help clients understand their legal rights. These include the Disability Law Show, online LTD FAQs and free consultations.
If your LTD benefits have been denied or cut off, contact Sivan Tumarkin and his team to explore your options and protect your right to the support you need. For a free consultation, call 1-855-821-5900 or email help@disabilityrights.ca to receive prompt, personalized guidance from a qualified long-term disability lawyer.