Traffic Accidents

Many people don’t know how to react during and after an accident and it can be easy to make a mistake. Listed is a step by step guide on what you should do during and after an accident in case you find yourself in this situation.

a) Things to do at the scene of an accident
  1. Get help for anyone injured. Do not move them. Keep them warm.
  2. Warn approaching traffic – don’t let one accident cause another.
  3. Call an ambulance if you think someone may be seriously hurt.
  4. Call the police if someone is injured or if there is substantial damage to the vehicle ($1,000).
  5. Co-operate fully with the police and obtain the incident number assigned to your case.
  6. Obtain the driver’s name, address, date of birth, telephone number, driver’s license number, driver’s license expiration date, insurance company name, insurance registration expiration date. Write down the year, make, model, license plate numbers of all the vehicles involved in the accident.
  7. Obtain names, addresses and telephone numbers of any passengers and witnesses to the accident. Ask them to stay and talk to the police. If they cannot stay ask them to explain to you what they saw and eventually write everything down.
  8. Identify people at the accident scene, even if they will not give you their contact information. If someone saw the accident and leaves the scene, you should make note of his/her license plate number.
  9. Do not give any opinion about the accident to other people.
  10. Seek medical attention as soon as possible.
b) Important things to do after an accident
  1. Inform your family doctor of your injuries.
  2. Call a lawyer for a free meeting so you may better understand your rights, obligations and options.
  3. Report the accident to your insurance company and ask them to send your accident benefits forms.
  4. Fill out and send all 3 accident benefits forms to your insurance company (Automobile Accident Benefits Proof of Claim, Employer’s Confirmation of Income & Benefits & Attending Physician’s Form). Keep copies.
  5. Do not speak or meet with insurance adjusters or claims investigators until you have spoken with a lawyer.
  6. If you are placed off work, notify your employer or school.
  7. If you are off work more than two weeks, contact employment insurance to make a claim for EI sick benefits. Call Service Canada – Toll Free: 1-800-206-7218).
  8. Take pictures of your injuries.
  9. Take pictures of damage done to your vehicle and possibly the other person’s vehicle.
  10. Record the names and contact information of your health care professionals.
  11. Keep track of your expenses and makes copies of all receipts.
  12. Family members should also record dates and times spent caring for the injured person.
  13. Check for other insurance coverage, such as short term and long term disability (ie. through your work, school or private plans).
  14. Follow the recommendations of your doctors and try to get into rehabilitation as soon as possible.
If you have been injured because of some else’s carelessness and recklessness, then you may have the right to make a personal injury claim. A claim against the fault driver is usually paid by the insurance company of the at fault driver. More than 95% of these claims are settled without going to court.

You should retain a lawyer who specializes in personal injury litigation and ensure your lawsuit is filed within the prescribed time limits in your province.

  • Pain and Suffering
  • Your loss of quality of life
  • Your past and future income and ability to earn income
  • Your health care expenses
  • Your housekeeping and home maintenance expenses
  • The effects of the accident on your family relationships
  • Your loss of future earning capacity and loss of competitiveness in the workforce
The $8,166.67 cap only applies to Pain and Suffering for MINOR injuries. It does not limit your claim for past lost wages, loss of future income, loss of earning capacity, medical expenses, cost of future care, loss of insurability, loss of housekeeping, home maintenance and more.
There may be sources of benefits available to you during the time before you receive a settlement from the insurance company.(i) Workplace BenefitsThe first source you may have at your disposal is workplace benefits. You will have to use these before being eligible for benefits from another source. These may include sick days, vacation days and any short-term disability plan, as well as any private medical plan that will cover the cost of medications, rehabilitation at medical clinics and other medical expenses.

(ii) EI Sickness Benefits

You may qualify for Employment Insurance or Sickness Benefits through the Government of Canada. These can provide you with up to 15 weeks of benefits that usually provide up to 55% of your weekly income.

(iii) LTD Insurance Benefits

You may be eligible to make a claim for long-term disability benefits if you are insured under a long-term disability insurance policy. People sometimes buy these policies directly from a broker, while others have it as a part of their workplace benefits. LTD insurance helps replace lost income if you cannot work. There are deadlines that limit the time you have to apply; if you have LTD coverage, look into it as soon as possible.

(iv) Motor vehicle insurance

If you are involved in a motor vehicle accident, you would have access to benefits through your own insurance company (known as Section B benefits).

Section B Benefits

(i) Medical Benefits Your motor vehicle accident benefits can cover a wide range of expenses, including:

  • Physiotherapy and chiropractic
  • Massage therapy
  • Psychology
  • Prescription medications
  • Medical equipment
  • Ambulance bills
  • Ambulance bills
  • Home modifications
  • Home modifications
  • Gym memberships
  • Mileage expenses between physician and therapy treatments

If your injury prevents you from returning to work, then your insurer is required to pay for vocational rehabilitation, return to work programs and modifications to your work space. Medical and rehabilitation benefits last up to 4 years or until you reach a maximum amount – whichever comes first (like a car warranty). The maximum benefits vary for each province:

  • New Brunswick: $50,000
  • Nova Scotia: $50,000
  • Prince Edward Island: $50,000

(ii) Weekly Loss of Income Payments

If your injuries keep you from working, you may qualify for weekly loss of income payments. The payments are 80% of your weekly income, up to a maximum of $250, depending on your province:

  • New Brunswick: maximum of $250 per week
  • Nova Scotia: maximum of $250 per week
  • Prince Edward Island: maximum of $250 per week

In order to qualify for weekly loss of income payments, you must meet the following criteria:

  1. You were employed at the time of the accident, or had arranged to start a new job soon, or were employed for 6 of the 12 months before the accident;
  2. Your injuries kept you from working for 7 day out of the 30 days following the accident; and
  3. You have not returned to work, or are earning less money because of your injuries.

(iii) Duration of loss of income payments

The duration of loss of income payments is determined by your ability to return to work. For the first two years, you must prove that you are unable to perform the essential duties of your own job. After two years, it is up to the insurance company to prove that you can work in a job that you qualify for based on your experience, training and background.

(iv) Housekeeping and home maintenance benefits

If you were not employed at the time of the accident and you are a homemaker, then you may qualify for payments for housekeeping services – snow removal, lawn mowing, etc. You cannot quality for weekly loss of income payments and housekeeping expenses – it has to be one or the other.

  • New Brunswick: maximum of $100 per week up to a maximum of 52 weeks
  • Nova Scotia: maximum of $100 per week up to a maximum of 52 weeks
  • Prince Edward Island: maximum of $100 per week up to a maximum of 52 weeks

(i) Accident Benefits Notice of ClaimFill this Form out and send it back to the insurance company right away.(ii) Medical Form

This form should be filled out by your family doctor. Make an appointment and take the form with you. Have the doctor fill it out while you are there. Take the form and send it back to the insurance company. The doctor may charge you a fee. Make sure the doctor writes down all his or her recommendations for treatment or medication. If your doctor wants you to stay off work for awhile make sure that is written on the form as well.

(iii) Employers Confirmation of Income & Benefits Form

If you are going to miss time from work, then you must get your employer to fill out this Form. Send it back to the insurance company right away. If you have not yet been provided with these forms, you can find them on our website.

  • Always send original documents to the insurance company and keep copies for yourself
  • If your doctor gives you a referral slip make sure he or she write on the slip that it is due to the motor vehicle accident
  • Fill-out and return the accident benefits forms as soon as possible.
  • Submit all medical expenses to your private insurance plan before you submit them to your accident benefits insurer (the accident benefits insurer does not have to pay for things that are covered under your private medical plan)
  • If your doctor is placing you off work, then his or her off-work note must give an estimate of the time you will be off, or at least when he or she will re-evaluate the ability to return to work.
  • If you plan to apply for loss of income payments you must also apply for short term disability benefits (if applicable) or Employment Insurance Sickness Benefits (Call Service Canada – Toll Free 1-800-206-7218)
Certain deadlines need to be respected; contact a lawyer for more information.
If this occurs, or understand that it is pending, please contact your lawyer immediately. There are many different reasons this may occur, so if they are notified right away, they can get specifics and investigate the problem to see if it is justified. Also, there is 12 months in which to start a lawsuit from the date of denial of benefits.
Occasionally, your Section B adjuster will want to seek direction from their medical advisor or consultants, which they are entitled to do under the Standard Automobile Policy. If so, it is essential that you advise your lawyer and your family physician of this, as soon as possible, so everyone is aware of the type of assessment and examiner. Also it is important to attend these appointments to prevent termination of your Section B benefits. These examinations may occur several times over the course of your claim. You are also encouraged to discuss the independent medical report with your family doctor to address any concerns and/or recommendations.
Yes, the Section B insurer must pay for the costs associated to attend the appointment, including mileage, meals, tolls, parking and overnight accommodations if necessary.
The Section B insurer has 30 days upon which you have submitted your expense to requisition payment.
Yes, you would be entitled to Section B benefits. Get in touch with a lawyer for more details.

Traumatic Brain Injuries

The brain is extremely fragile. It is made up of a complex system of interconnected neurons, much like circuits in a computer chip. When a group of neurons is damaged and dies, the neuron with which they communicated no longer receives information. Once these neurons no longer receive signals from the damaged neurons, they become inactive and eventually die. This is a process known as the cascade effect, and it is how an injury to one part of the brain will, over time, result in damage to the surrounding areas. That is why treatment and intervention are critical during recovery after a brain injury.

There are two types of TBI open brain and dosed brain. They are determined by the way the brain was injured.(i) Open-Brain InjuryA gunshot wound is an example of an open-brain injury. The skull and the protective membranes are pierced, and the bullet destroys brain tissue.

(ii) Closed-Brain Injury

A closed brain injury is caused by a blow to the brain, such as from a vehicle collision, a fall, or a rapid acceleration. Closed-brain injuries tend to be less obvious than open brain injuries, and can be overlooked as there may be no visible signs of damage to the skull.

The inside of the skull has many bony ridges, and a violent acceleration or deceleration can cause the brain (which has the consistency of Jell-O) to impact them and cause significant damage. If the impact is strong enough, the brain will bang against the inner wall of the skull and result in a coup injury. This can cause a contusion, or bruise. In some cases the brain will then rebound off the opposite side of the skull, causing another contusion on the other side of the brain – this is called a countercoup injury. Depending on the force of the initial blow, these rebounds can happen several times. With each back and forth motion, the brain can sustain bleeding and tissue damage. It is not necessary for a person to lose consciousness in order to sustain a TBI. After sustaining the injury, the victim may feel dazed or remain completely alert.

(i) Edema Frequently, following a brain injury, the brain swells due to an increased flow of blood to the injured tissue. Often this swelling is accompanies by a collection of water inside the skull. This collection of water or edema causes the pressure within the skull to increase which can cause further damage to the brain.(ii) Hematoma

The brain is supplied with blood through an extensive network of blood vessels. Following a brain injury, some of these blood vessels may rupture, which can lead to the formation of a pool of blood known as a hematoma. Like the edema, a hematoma increases the pressure inside the skull and can damage the brain.

(i) Diagnosing a TBIMost injuries, including some TBIs, can be seen in different ways, either with the naked eye or with medical imaging tools like MRI or CT scans. Many TBIs, however, will not be visible in those scans – but that doesn’t mean the injury is not here.Symptoms may not be immediately visible.

The symptoms of a TBI are not always immediately obvious after the accident. You may only feel different several days, weeks or months later, when you return to work or resume your usual daily activities.

  • Pain in the head, neck or back
  • Loss of ability to read, write, speak, hear or see
  • Loss of mobility and muscle control
  • Increased sensitivity to noise, touch or certain types of lighting
  • Loss of memory
  • Confusion
  • Poor or inappropriate language
  • Sudden emotional outbursts
  • Anxiety attacks
  • Changes in personality
The severity of the injury does not necessarily predict how severe an impact it will have in the victim’s life. Most Traumatic Brain Injuries are classified as ”mild” but that does not mean the impact on the person’s life is any less serious. The size of the injury, its cause and most importantly its location are what will mostly determine the severity of the injury’s impact on the victim’s life. In the past, so-called ”minor” brain injuries were often ignored. People would simply walk it off and were assumed to be fine afterwards. Public awareness of brain injuries has increased in recent years, particularly due to reports of professional athletes sustaining concussions that have put them out of work for an entire season, or even ended their sports career. Furthermore, brain injuries are too frequently overlooked in the emergency room. The more obvious and visible injuries take precedence and it may be weeks, months or years before the patient notices issues, such as memory loss or personality changes, that are due to an undiagnosed TBI. With that being said, there is really no such thing as a ”mild” brain injury – any injury to the brain is significant. The effects of a ”mild” brain injury can be devastating, sometimes more so than with a ”severe” brain injury.
There is a common misconception that all minor TBIs will heal in time, this is not true. A year after the accident, 10% to 15% of mild TBI victims have not recovered, and many have symptoms that have worsened. This is known as Chronic Post-Concessive Syndrome.
The goal of rehabilitation is to help TBI victims be as independent as possible. The rehabilitation process is different for everyone and must be specific to each person’s needs. Rehabilitation happens on two levels: medically and community-based.

There are some things that family members need to keep in mind during rehabilitation process:

  • Never give up hope.
  • Maintain a journal and keep accurate records of all your experiences and changes you observe with your loved one.
  • Include your loved one in discussions and activities.
  • Communicate and advocate.
  • Take time to care for yourself.

One of the most important things you can do for yourself (or a family member who has suffered a brain injury) is to establish a good support system as soon as possible.

As well as including doctors with knowledge of – or a specialty in – brain injury, caregivers, physiotherapists, and others, this term may also include a legal team that will provide you with the best and most up-to-date legal advice.

Rehabilitation can be expensive, both for individual treatments and for the duration of time they may be necessary. Past and future rehabilitation costs should be included in your insurance claim.

Spinal Cord Injuries

The brain controls the body’s activity by using the nervous system to send and receive small electrical pulses. It sends signals through the nerves to activate muscles, and receives signals to process our sense of touch. The spinal cord is the main “pipeline” for the nervous system – nerves run through it, up the neck and into the brain. An injury to the nerves in the spinal cord can limit or eliminate the brain’s ability to communicate with parts of the body.(i) Complete v. IncompleteAn injury is considered “complete” when there is complete loss of sensation and voluntary movement below the level of the injury. For example, paralysis is a complete injury. If there is still partial movement or sensation, the injury is considered “incomplete”.

(ii) Traumatic and Non Traumatic Spinal Cord Injuries

There are two types of spinal cord injuries: traumatic and non-traumatic. Traumatic injuries are sustained in an accident, and non-traumatic injuries are caused by diseases or congenital disorders like Spina Bifida.

(iii) Traumatic Spinal Cord Injury

Thousands of Canadians suffer an accidental spinal cord injury each year. The two types of accidents that cause the most spinal cord injuries are falls and motor vehicle accidents. A SCI may cause you to miss weeks, months or years of work, or you may be unable to ever work again. Recovery from a SCI can also involve physical, occupational and psychological therapy, as well as extensive medical care. These things can case a serious financial burden on your family.

Repairing damage to the spinal cord has been shown to be possible, but medical advances have not yet provided a cure for paralysis. Most current efforts therefore center on rehabilitation and improving the quality of life of injury victims.

Spinal cord injuries can present different symptoms based on the location and the severity of the injury. Symptoms may include pain, numbness or a complete loss of sensation in the affected areas. In some cases muscles may move uncontrollably, become weak, or completely unresponsive. Areas affected by damage to different points in the spinal cord include neck, arms, hands (and below), torso (and below), hips, legs and feet. (i) Spinal Cord Impairment ScaleThe severity of spinal cord injuries can be described using a scale developed by the American Spinal Injury Association. The scale is based on injury victims’ responses to touch, as well as the strength of specific muscles.

  • A indicates a “complete” spinal cord injury, with no remaining sensation or movement.
  • B indicates an “incomplete” spinal cord injury where there is still a slight sense of touch, but no movement. This phase is often temporary, with victims regaining some movement and moving to “C” or “D” on the scale.
  • C indicates an “incomplete” spinal cord injury where at least half of muscles have mobility but it is much weaker than normal.
  • D indicates an “incomplete” spinal cord injury where at least half of muscles have mobility but it is somewhat weaker than normal.
  • E indicates “normal” with complete movement and sensation. Note that it is still possible to have a spinal cord injury even with normal movement and sensitivity.
Paraplegia and Tetraplegia (also called Quadriplegia) are two severe forms of paralysis that can result from a SCI. Paraplegia consists of paralysis from the waist down (loss of sensation and movement in the legs), which is usually caused by an injury to the lower back. Tetraplegia is paralysis from the neck down (including arms, legs and the torso), which results from an injury to the neck.

(i) Medically-Based RehabilitationMedically-based rehabilitation is adapted to meet the needs of each individual. The most common examples of this form of rehabilitation include:

  • Early intervention: Rehabilitation starts immediately after the injury and includes paramedics, trauma health professionals, family members and the intensive care unit
  • Acute rehabilitation: Once a person is medically stable they are usually transferred to an acute rehabilitation facility where they will spend several hours a day in a structured rehabilitation program.
  • Sub-acute rehabilitation: If an individual is medically stable and is unable to participate in acute rehabilitation due to limitations, a less intensive level of rehabilitation is implemented.
  • Day treatment: Provides intensive rehabilitation in a structured setting during the day and allows for the individual to return to the residence at night.

(ii) Community-Based Rehabilitation

  • Rehabilitation facilities: Additional rehabilitation in more specific areas may be provided in an outpatient facility.
  • Home-based rehabilitation: Rehabilitation companies and/or individual professionals who focus on rehabilitation within the home and community.
  • Community re-entry: Day programs which focus on developing a higher level of motor and cognitive skills to prepare the individual for re-entry into the community. Day programs can also be at a less intensive level of rehabilitation for individuals with limited attention and/or stamina.
  • Independent living programs: Housing specifically for individuals with disabilities, whose goal is to regain the ability to live as independently as possible.
  • Spinal cord associations: These offer support groups, peer support, information and education.

There are some things that family members need to keep in mind during the rehabilitation process:

  • Never give up hope.
  • Maintain a journal and keep accurate records of all your experiences and changes you observe with your loved one.
  • Include your loved one in discussions and activities.
  • Communicate and advocate.
  • Take time to care for yourself.

One of the most important things you can do for yourself (or a family member who has suffered a spinal cord injury) is to establish a good support system as soon as possible. As well as including doctors with knowledge of – or a specialty in – spinal cord injuries, caregivers, physiotherapists, and others, this team may also include a legal team that will provide you with the best and most up-to-date legal advice.

Rehabilitation can be expensive, both for individual treatments and for the duration of time that they may be necessary. Past and future rehabilitation costs should be included in your insurance claim.

Therapy is very important in spinal injury cases, particularly those involving paralysis. Therapy generally centers on helping the injury victim learn to complete routine tasks, as well as the prevention of complications that may arise due to the injury.
Improving the mobility of affected areas is sometimes a possibility, but there are currently no treatments that provide regeneration of the damaged nerves. In incomplete injury cases (where the victim still has some movement and sensation) therapies involving treadmills and electrical stimulation may help restore some motor skills.

Prevention of complications is more important in cases of paralysis, particularly paraplegia and tetraplegia. Since entire parts of the body are unable to move, problems like muscle atrophy (muscle wasting away from lack of use) or osteoporosis (weakening of bones) may arise. Osteoporosis, for example, would increase the chances of breaking a bone in the affected parts of the body. Therapy to help avoid those issues can include training where weight is applied to the paralyzed limbs to help maintain muscle mass and bone strength. Psychological therapy may also be necessary to help the SCI victim adjust to his or her new situation – this can address issues of self-confidence and also of sexual health, which is often affected in cases of paralysis. (i) Around the Home

Assistive devices (a wheelchair, for example) can greatly affect quality of life and allow a greater level of mobility. In such cases, modifications to the injured person’s home may be required – adapting stairs and washrooms or adding grab bars, for example.

Therapy and training is useful to help the injured person learn how to transfer from different positions (such as from a wheelchair to a bed) and retain some mobility around the house. Some people will also be able to return to driving in an adapted vehicle.

Long-term Disability Benefits

Long Term Disability (LTD) insurance pays you a portion of your lost income if you become to disabled to work.

LTD Insurance in Canada is regulated at the provincial level and is therefore governed by your provinces’ laws, which may include:

  • Insurance Act
  • Statute of Limitations
  • Rules of Court
If you drive a car, you have must have insurance. Since car insurance is legally required, all car insurance policies in that province are fairly similar and must offer a minimum amount of coverage. Disability insurance polices are different. Because you are not obligated to have an LTD policy, there is no legally defined minimum or “standard” coverage. That means all LTD polices are different and can vary greatly from one to the other.
Even though you receive your LTD coverage through your employer, you do not need to have been injured at work to qualify for long term disability benefits. LTD insurance is not there to compensate you for workplace accidents – it is to replace your income if you become unable to work.
Most LTD policies cover you no matter what injury or disability prevents you from working – the key point is that you are not able to work. Some policies, however exclude certain specific illnesses; other may exclude illnesses; others may exclude illnesses that are compensable under a work place compensation claim. Note that the disability must have happened since the time your LTD insurance was active, so any disability you had before you got your insurance will be excluded.
Generally you will qualify for LTD benefits if you are not able to do all (or most) of the duties of your job. Some policies say you must be “completely disabled” to qualify for benefits. That is usually just a different way to state the point above – that you must be unable to perform the normal functions of your usual job. It does not necessarily mean that you must be completely unable to do any part of your job at all – just that your disability is such that it would be better for you to stop working so you can focus on getting better. Certain policies also require that, to qualify, you must be unable not only to do your current job, but any job for which you are qualified. Your policy documents will have full details.
You need to be off work for several months before you can access LTD coverage – this is called the “elimination” or qualifying period and it generally ranges from 90 to 180 days (3 to 6 months). Your policy will specify the exact waiting period that applies to you. The waiting period exists to ensure that injuries are truly “long term” and not something that will heal in the next few weeks. In the short term you have access to Short-Term Disability coverage (also called a Weekly Indemnity benefit plan) – those benefits will be available after a much shorter waiting period. If you do not have access to Short-Term Disability or Weekly Indemnity benefits you may qualify for Employment Insurance Sickness Benefits through the Government of Canada. These can provide you with up to 15 weeks of sick benefits that usually provide us to 55% of your weekly income.
Many LTD policies allow the insurance company to have you assessed by the doctor of their choice to decide whether you are entitled to benefits. If that happens, the doctor chose by the insurance company must be reasonably qualified to do the assessment and the exam itself must be reasonable. If you refuse (without good reason) to see the insurance company’s doctor, you will be in breach of the insurance policy, which may be grounds for the insurance company to deny your claim. This is often an area of great concern; if you have any doubts or questions, it may be in your best interest to seek the advice of a qualified lawyer.
Insurance companies often hire outside companies to follow, photograph and record people who make LTD claims. They do this to ensure you are truly disabled and to minimize fraudulent claims. That means it is particularly important to be honest and open with your doctors, specialists, the insurance company and your lawyer. If you are honest and open, nothing they videotape or photograph will hurt your case. In fact, it can be helpful to have that evidence, as it usually shows that you are in fact disabled. Generally speaking, this type of surveillance is legal. Most investigative companies obey the law and do not engage in anything that could be considered trespassing or an invasion of your privacy. However, if at time you feel in danger, you should contact the police.
LTD policies typically pay 2/3 of the pre-disability salary (66.6%) but they may range between 50% and 80%. Some policies also have a minimum monthly payment which may cap the total amount you receive. Your policy will specify the amount you are entitled to.

Most LTD policies are intended to top up the disability benefits available to you elsewhere. This means LTD policies usually deduct the amount you receive from other sources such as:

  • Benefits from any Worker’s Compensation plan
  • Disability benefits received from any other government program like CPP or EI sickness benefits
  • Income from a crime victim compensation program
  • Wages from any employer, including any severance pay
Often your LTD benefits can also be reduced by the amount payable to your dependents (children, for example) as well. One very common example of this is the deduction of benefits payable to the children of a person receiving CPP Disability. If your insurance company makes this deduction, you should speak with a lawyer right away.
Often yes, many policies allow the insurance company make you apply for benefits from another source (like CPP or Worker’s Compensation), since these additional benefits would be deducted from the payments you receive from the insurance company. If you choose not to apply for these benefits, the insurance company may still deduct your monthly benefits the amount you have been entitled to receive. If you apply for other benefits and you are denied, they may also be able to make you appeal the decision. If you are asked to do something like this, ask the insurance company representative to show you which part of the policy gives them the power to ask you do this.
If your employer was paying for your LTD insurance, your benefits will be taxed. If you were paying for the insurance yourself, they will not be taxed. If you were each paying a portion of the insurance premium, you may need a legal opinion on the taxation that will apply.
No. LTD benefits serve only to replace your income and do not include any additional benefits that you may have been receiving from your employer. You may be able to keep your workplace medical plan while you are on LTD, but that would be arranged between you and your employer, not the LTD insurance company.
Most plans last until you are 65 years old. Some plans, however, have a specific time frame – for example 5 or 10 years, or even as low as 2 years.
First, read the letter you received from the insurance company and find out why they have denied your claim. Their reason may be something as simple as a clerical error, or they may be missing a key piece of paperwork. In many cases they require a form to be filled out by your doctor before making a decision – if that is the case, you should immediately make arrangements with your doctor and make sure the insurance company has all the forms it needs to process your claim. The insurance company may also have refused your benefits due to an issue with your employer. In that case, you should contact your employer immediately because the employer is often able to assist you in getting the insurance company to fairly process your claim. If you have submitted all proper paperwork and your doctor supports your claim but the insurance company still refuses your claim, you have two remaining courses of action: doing an internal appeal with the insurance company, or taking legal action, which generally involves suing the insurance company to obtain your benefits. If you have submitted all proper paperwork and your doctor supports your claim, but the insurance company still refuses your claim, you have two remaining courses of action: doing an internal appeal with the insurance company, or taking legal action, which generally involves suing the insurance company to obtain your benefits.

My insurance company says that after two years they can stop paying me if I can work somewhere else. Is this true? Most LTD policies state that for the first 24months years), you are entitled to claim LTD benefits if you cannot perform the essential duties of your own occupation. This is called the “Own Occupation Test”. After that two-year period, your eligibility for LTD will be based on whether you are unable to do any occupation for which you are reasonably qualified (or could become qualified for). That is called the “Any Occupation Test”. Those conditions can vary greatly from one policy to the next. Some policies are “Own Occupation” until age 65, meaning you are entitled to benefits all the way up age 65 unless you become able to do your usual job again. Others are “Any Occupation” from the start. Courts have said that “Any Occupation” does not mean literally any job – it must be a position for which you are not overqualified or unsuited by background and where you will not be doing trivial work.

Additionally, some insurers will provide you with vocational training to help you find another job that is more suitable for you if your disability is ongoing and prevents you from returning to the job you had before you became disabled.

With most LTD policies, what matters is when you became disabled. As long as you were actively employed at the time you became disabled, your termination should not affect your LTD benefits. However, if you receive a severance payment from your employer, that amount may in some cases be deducted from your LTD benefits. The situation can become more complicated if you were not actively employed when you became disabled (for example if you were temporarily laid off) or if your employment was terminated while you were on short-term disability. A qualified lawyer can assist you with this situation.
First and foremost, it’s important to read the insurance company’s letter very carefully. They may have terminated your benefits for any number of reasons: If your benefits were terminated because a form is missing or some information was not provided, contact the insurance company immediately and try to get the paperwork to them as soon as possible. If your benefits are being terminated because the insurance company does not believe you are disabled, speak to your doctor and ask if he or she believes you meet the Own Occupation or Any Occupation test which applies to you. If your doctor believes you are disabled according to the appropriate test, have them write a letter to the insurance company confirming their opinion. Sometimes the insurance company will terminate benefits even if your doctor believes you are still disabled. In this case you may need to take legal action to reinstate your LTD benefits.

If you meet the requirements of the LTD policy and your doctor has confirmed that you are disabled – but the insurance company still refuses your claim – you have two remaining courses of action:(i) Internal Appeal Most insurance companies provide an appeals process for denied claims. They will review your file again (including any new information that you may have submitted) and come back to you with a decision, usually after 60 or 90 days. There may be two or more levels of appeal. In most cases, internal appeals are not mandatory.

(ii) Suing for Benefits

If the internal appeal is unsuccessful (or if you have decided to sue right away) you can begin a lawsuit to obtain your benefits. At this point in the process, suing is your last possible course of action.

In all LTD lawsuits, you sue for the payment of the disability benefit to which you are entitled. If the denial of your claim caused you to suffer a great amount of stress, you can sue for compensation for “mental distress” You can also claim pre- and post-judgment interest on the amounts claimed, as well as a contribution from the defendants towards your legal fees. Some lawsuits may also include punitive damages for “bad faith”. This is rare and only awarded if the insurance company has acted in a particularly malicious, vindictive and harsh manner.
In most LTD cases, you sue the insurance company that is refusing to pay your benefits. Sometimes it may be necessary to sue your employer or a non-profit board of trustees that administrates your LTD plan. In some rarer cases you may need to sue the broker who sold you the policy. What is the process involved in suing the insurance company? Generally, the court process begins by delivering a Statement of Claim (commonly called a lawsuit) which sets out the allegations you are making against the insurance company. Once the insurance company receives it they will immediately stop any ongoing internal appeal.
The insurance company will then file a defense against your lawsuit and documents will be exchanged. At some point, you will be asked questions under oath and you will likely need to undergo medical assessments, both with your own doctor and the doctor for the insurance company. Usually there are then settlement negotiations, where both sides attempt to come to an agreement. This may lead to a mediation or settlement conference. If that is not effective, the matter will go to trial.