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My Doctor Says I Can’t Work. My Disability Insurer Disagrees. What Now?
Your doctor says you cannot work. Your disability insurer disagrees. This is one of the most common and frustrating situations employees face when applying for long-term disability benefits in Ontario. Understanding why this happens, what insurers are actually assessing, and what steps you can take to challenge the decision gives you the best chance of getting the benefits you are entitled to.
Has your LTD insurer rejected or questioned your claim despite your doctor's support?
A denial based on insufficient medical evidence can often be successfully challenged. The deadline to appeal is usually 30 to 90 days. Get legal advice before that window closes.
Call: 1-800-771-7882 Speak With an LTD LawyerHow the LTD application process works
Most employees access long-term disability benefits through their employer's group benefits plan. To apply, you typically submit three forms together. The insurer's case manager, who is not a doctor, reviews these forms and decides whether your medical evidence meets the policy's definition of total disability.
Plan Member Statement
Completed by you. Describes your condition, symptoms, work history, and how your condition affects your ability to do your job.
Plan Sponsor Statement
Completed by your employer. Confirms your job duties, hours, earnings, and the date you stopped working.
Attending Physician Statement
Completed by your treating doctor or specialist. The most critical form. It outlines your diagnosis, functional limitations, treatment plan, and the expected duration of your disability.
Why your insurer might disagree with your doctor
Even where your doctor clearly supports your leave, your insurer may claim there is insufficient medical evidence to approve the claim. This decision is made by a case manager, not a physician. The case manager applies the policy's definition of total disability to the documentation on file. The following are the most common reasons insurers dispute claims despite physician support.
Your claim was denied for insufficient medical evidence. That is not the end.
Many valid LTD claims are denied on this basis and are successfully overturned on appeal. A lawyer can review your file, identify what the insurer is relying on, and help you build a stronger response before the appeal deadline passes.
Get Your Denial Reviewed Or call us: 1-800-771-7882What to do when your insurer disputes your claim
Ask for specifics in writing
Request a written explanation from your case manager stating exactly what information they believe is missing or insufficient. This identifies the precise gap you need to address and creates a record of the insurer's position.
Request a medical questionnaire for your doctor
Ask the insurer to send a targeted medical questionnaire to your treating doctor. This allows your doctor to provide clear, specific answers about your condition, functional limitations, and why you cannot work, directly addressing what the insurer says is missing.
Gather supporting reports from all treating providers
If you see multiple healthcare providers including a psychiatrist, psychologist, physiotherapist, or occupational therapist, submit supporting letters and reports from each of them. Multiple providers documenting consistent limitations significantly strengthens your file.
Keep records of every communication
Save copies of all emails, letters, and notes from phone conversations with your insurer. If your claim is denied or your appeal is needed, these records are critical evidence. Note dates, times, and what was said in every interaction.
Get legal advice before the appeal deadline
Most insurers allow 30 to 90 days to appeal a denial. A lawyer experienced in long-term disability disputes can review your policy, identify what the insurer is relying on, and help you build a stronger appeal before that deadline expires.
What happens when your claim is denied
A denial based on insufficient medical evidence is not the end of your claim. Denials on this basis are regularly overturned on appeal and through litigation. The following options are available to you.
Request reconsideration or file an internal appeal
Most insurers have an internal appeal process. Submit additional medical evidence, updated reports from your doctor, and any other documentation that addresses the insurer's stated concerns. Pay close attention to the appeal deadline in your denial letter.
Obtain updated medical evidence
Ask your doctor and any specialists to provide updated reports that specifically address the insurer's stated concerns. Where the insurer has cherry-picked a single reference to "improvement" while ignoring the broader picture, an updated report clarifying the full clinical picture can be decisive.
Consult a disability lawyer
A lawyer can review your policy's definition of total disability, identify missing or misinterpreted evidence, communicate with the insurer on your behalf, and file a lawsuit for LTD benefits if the claim continues to be denied. Legal representation levels the playing field significantly in disputes with insurers.
Key points to remember
Frequently asked questions about LTD disputes in Ontario
Why would my insurer deny my LTD claim if my doctor supports it?
Insurers apply their policy's definition of total disability to the documentation on file. A case manager, who is not a physician, makes the decision. If the medical documentation does not clearly connect your symptoms to your inability to perform specific job duties, or if there are treatment gaps or notes the insurer interprets as evidence of improvement, the claim may be denied or questioned even with physician support. This is a common tactic that can often be challenged successfully.
What does "insufficient medical evidence" mean in an LTD denial?
It typically means the insurer's case manager believes the documentation does not clearly establish that your condition prevents you from performing the duties of your occupation as defined by the policy. It does not necessarily mean your condition is not serious. In many cases it means the documentation needs to be more specific about your functional limitations and how they relate to your job requirements.
How long do I have to appeal an LTD denial?
Most insurers set appeal deadlines of 30 to 90 days from the date of the denial letter. Missing this deadline can significantly affect your ability to pursue the claim. Review your denial letter carefully for the specific deadline and get legal advice as soon as possible after receiving a denial.
Can I sue my insurer if my LTD appeal is denied?
Yes. If your internal appeal is unsuccessful, you can commence legal proceedings against the insurer for LTD benefits. Courts regularly find in favour of claimants where insurers have improperly denied or terminated benefits. Limitation periods apply to these claims, so consulting a long-term disability lawyer promptly after a final denial is important.
Can my employer terminate me while I am on LTD or appealing a denial?
Being on LTD or disputing a denial does not provide automatic protection from termination. However, terminating an employee because of their disability or medical condition may violate the Ontario Human Rights Code and give rise to a wrongful dismissal claim. If your employer has taken action against your employment in connection with your disability leave, get legal advice promptly.
Speak with an Ontario LTD lawyer
If your disability insurer has disputed or denied your claim despite your doctor's support, our team can help. We advise employees across Ontario on long-term disability claims, insurer disputes, and appeals. Contact us for a confidential consultation before your appeal deadline passes.
Call us at 1-800-771-7882 or fill out the form below and we will be in touch.