My Doctor Says I Can’t Work. My Disability Insurer Disagrees. What Now?
Applying for long-term disability (LTD) benefits can already feel overwhelming medical forms, case managers, treatment plans, and paperwork. But what happens when your doctor says you can’t work, yet your disability insurer disagrees?
It’s a common and frustrating scenario. Your insurer might say there’s “insufficient medical evidence” to support your claim even when your doctor has provided clear support for your medical leave.
Here’s what that means, why it happens, and what you can do about it.
Understanding Long-Term Disability Benefits
Most employees have LTD coverage through their employer’s group benefits plan or an individual insurance policy. These benefits replace a portion of your income if you’re unable to work due to illness or injury.
To apply, you typically submit three forms:
- Plan Member Statement (PMS): completed by you, describing your condition and work history.
- Plan Sponsor Statement (PSS): completed by your employer.
- Attending Physician Statement (APS): completed by your treating doctor or specialist.
The Attending Physician Statement is crucial. It outlines:
- Your diagnosis and symptoms;
- Functional limitations and restrictions;
- Current or planned treatments; and
- The expected duration of your disability.
Why Your Insurer Might Disagree With Your Doctor
Even though your doctor supports your leave, your case manager (who is not a doctor) decides whether your medical evidence meets your insurer’s definition of “total disability” under the policy.
Insurance companies often say there’s “not enough medical information” for one or more of the following reasons:
- Your medical records don’t clearly link your symptoms to your inability to work.
- Progress notes mention “improvement” or “stability,” which insurers sometimes misinterpret as readiness to return to work.
- There are gaps in treatment or missing specialist reports.
The insurer’s internal medical consultant (who has not examined you) disagrees with your doctor’s opinion.
In these cases, the insurer may:
- Request a functional telephone interview;
- Arrange an independent medical examination (IME); or
- Have their own doctor conduct a paper review of your file.
How to Respond When Your Insurer Disagrees
1. Ask for Specifics in Writing
Request a written explanation of what information they believe is missing. This can help your doctor address the gaps directly.
2. Request a Medical Questionnaire
You can ask the insurer to send a medical questionnaire to your treating doctor. This lets your doctor provide clear, targeted answers about your condition, limitations, and treatment.
3. Provide Additional Medical Support
If you’re seeing more than one healthcare provider, for example, a psychiatrist, psychologist, physiotherapist, or occupational therapist, you can submit supporting letters or reports from them. These can strengthen your file and show the insurer that your disability is well-documented.
4. Keep a Record of All Communication
Maintain copies of all emails, letters, and notes from conversations with your insurer. If your claim is later denied, these records can be crucial evidence in an appeal or lawsuit.
When Your Claim Is Denied for “Insufficient Medical Information”
It’s not uncommon for insurers to deny valid claims using this vague explanation. You may even see portions of your medical file cherry-picked, such as a single note about “slight improvement,” while the rest of your medical evidence is ignored.
A denial doesn’t mean the end of your claim. You have options:
- Request a reconsideration or internal appeal within the insurer’s deadline (usually 30–90 days).
- Submit additional medical evidence or clarification from your treating doctor.
- Consult a disability lawyer before or during the appeal process to strengthen your response and ensure your rights are protected.
Why Legal Help Matters
Disability insurance companies are skilled at interpreting policies narrowly. A lawyer experienced in long-term disability disputes can:
- Review your policy’s definition of “total disability”;
- Identify missing or misinterpreted evidence;
- Communicate directly with the insurer; and
- File a lawsuit for LTD benefits if your claim continues to be denied.
Legal representation levels the playing field and ensures the insurer doesn’t misuse medical information or pressure you into returning to work too early.
Key Takeaways
- Your doctor’s opinion matters, but insurers often rely on their own consultants.
- Always request written clarification from your case manager.
- Gather evidence from all treating professionals.
- A denial based on “insufficient information” can often be challenged successfully.
Need Help With a Disability Claim Denial?
If your long-term disability insurer disagrees with your doctor or denies your claim for “insufficient medical evidence,” you don’t have to face it alone.
At Achkar Law, our disability and employment lawyers assist employees across Ontario and Canada in challenging LTD denials and negotiating fair settlements.
The article in this client update provides general information and should not be relied on as legal advice or opinion. This publication is copyrighted by Achkar Law Professional Corporation and may not be photocopied or reproduced in any form, in whole or in part, without the express permission of Achkar Law Professional Corporation. ©