What to Do When Your Long-Term Disability Claim Is Denied
A denial letter is not necessarily the end of a long-term disability claim. It is the insurer’s current decision, based on the policy wording and the evidence it says it reviewed.
Before you respond, it usually helps to review the denial letter, the policy or benefits booklet, the medical and functional evidence, and the important dates in the file.
The right next step depends on those documents — not on a generic deadline or a one-size-fits-all appeal script.
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Immediate steps after a denial
- Read and preserve the full denial letter, including attachments and envelope or email headers.
- Obtain the policy or benefits booklet that governs the claim.
- Request the insurer’s claim file and relevant medical records where appropriate.
- Avoid assuming that an internal appeal automatically preserves every legal right.
- Get advice before signing releases, return-to-work documents, or settlement paperwork.
These steps are general guidance only. Applicable deadlines and starting dates can be fact-specific and should be confirmed from the actual policy and correspondence — not from a universal rule of thumb.
What the denial letter means
Most denial letters try to explain why benefits were refused. Reading the letter carefully helps you see what the insurer relied on — and what it may have left out.
Policy definition relied upon
The letter usually identifies the disability definition the insurer applied — for example, whether it assessed you against your own occupation or a broader standard.
Medical or functional evidence cited
It often summarizes reports, clinical notes, or assessments the insurer says support the denial.
Claimed evidentiary gaps
Many letters argue that records are incomplete, outdated, or do not explain functional limits clearly enough.
Appeal process offered
The insurer may describe an internal review or appeal process and ask for further information by a stated date.
Dates stated by the insurer
Look for the decision date, any response deadline the insurer sets, and dates tied to benefits or medical reviews.
Return-to-work or rehabilitation position
Some letters say you can work, participate in rehabilitation, or accept modified duties. Those positions should be checked against the actual job demands and medical restrictions.
Common reasons insurers may give for denial
The points below are reasons an insurer may give. Listing them here does not mean every reason is legally valid, complete, or decisive in a particular claim.
Insufficient medical evidence
The insurer may say the file does not contain enough detail about diagnosis, treatment, or ongoing impairment.
Ability to perform the occupation
The insurer may conclude you can still do your own job, or another occupation, based on its reading of the medical and vocational evidence.
Lack of objective findings
Especially in pain, fatigue, or mental-health claims, insurers may argue there are too few “objective” test results.
Failure to follow treatment
The letter may allege missed appointments, incomplete rehabilitation, or non-compliance with recommended care.
Pre-existing-condition limitation
Some policies limit or exclude coverage where symptoms or treatment pre-date coverage. Whether that limitation applies depends on the wording and medical history.
Missed procedural requirements
Insurers sometimes rely on late forms, incomplete applications, or missed information requests.
Surveillance or social-media evidence
The insurer may point to video or online activity as proof of capacity. Context and sustainability still matter.
Disagreement about functional limitations
Even where a diagnosis is accepted, the insurer may dispute how the condition limits work capacity day to day.
Internal appeal or legal action?
There is no single answer that fits every denial. An internal appeal and legal action can serve different purposes, and the better path depends on the evidence, the policy process, timing, and your circumstances. One path is not always better than the other.
| Factor | Internal appeal | Legal action |
|---|---|---|
| New medical evidence | May help if updated reports, testing, or specialist opinions can realistically address the gaps the insurer identified. | Still useful later, but the immediate question is whether waiting for an appeal cycle is necessary before broader options are considered. |
| Evidence already on file | Can be appropriate where the denial appears to overlook or misstate existing medical or occupational evidence. | May be considered sooner if the insurer’s reading of the file looks entrenched or incomplete despite prior submissions. |
| Appeal wording and procedure | The policy and denial letter may describe a process, deadlines set by the insurer, and what information is requested. | The procedural effect of that process — including what it does and does not preserve — should be confirmed before treating the appeal as complete protection. |
| Time already elapsed | Can still be useful early after a denial if evidence can be assembled promptly. | Becomes more urgent as correspondence ages, prior appeals accumulate, or critical dates approach. Exact deadlines are fact-specific. |
| Financial and health circumstances | May be manageable where benefits interruption is recent and medical care remains stable enough to obtain records. | May need earlier attention where income loss, treatment access, or claim complexity make delay costly. |
| Preserving litigation rights | Should not be assumed to pause or replace every legal timeline on its own. | May require prompt review of the policy, correspondence, and applicable limitation rules using the actual documents. |
May help if updated reports, testing, or specialist opinions can realistically address the gaps the insurer identified.
Still useful later, but the immediate question is whether waiting for an appeal cycle is necessary before broader options are considered.
What an LTD lawsuit involves →
An insurer’s appeal process and the deadline for starting a legal proceeding are not necessarily the same thing. An internal review should not be assumed to pause or extend a legal limitation period. The applicable starting date can depend on the policy, the insurer’s correspondence, the history of the claim, and whether legal proceedings had become an appropriate means of seeking a remedy.
Ontario has a general two-year statutory limitation framework, but that does not mean every LTD claimant has two years from a single universal date such as the initial denial, the termination date, the final internal appeal, or the last benefit payment. The start date can be fact-specific.
A policy may contain contractual timing language. The existence of that language does not by itself establish that it is enforceable, that it applies to a particular claimant’s circumstances, that it displaces the statutory framework, or that an action is late. Defeating a contractual limitation argument also does not necessarily establish entitlement to benefits.
Kassburg v. Sun Life (2014)
In Kassburg v. Sun Life Assurance Company of Canada, 2014 ONCA 922, Sun Life’s appeal was dismissed. On the wording and documents before the Court, a contractual one-year provision was not enforceable. The Court addressed ambiguity in the contractual materials and the application of the Limitations Act’s business-agreement framework. The result was specific to that wording and those circumstances — it does not mean every one-year contractual limitation is unenforceable, or that every group LTD policy receives the same treatment.
Thompson v. Sun Life (2015)
In Thompson v. Sun Life Assurance Company of Canada, 2015 ONCA 162, the Court found that the motion judge had not completed the analysis required before enforcing a contractual one-year provision under the Limitations Act’s business-agreement framework. The claimant’s appeal was nevertheless dismissed on a separate policy-eligibility ground. Thompson is not a claimant victory on the limitation issue, and it does not establish a universal start date for every claim.
Clarke v. Sun Life (2020)
In Clarke v. Sun Life Assurance Co. of Canada, 2020 ONCA 11, Sun Life’s appeal was allowed in part and the summary-judgment determination was set aside. The Court of Appeal did not finally decide that the claim was timely or late. It required a fuller factual record before the appropriate-means component of discoverability — and the possible significance of an informal appeal process — could be resolved. The matter was remitted rather than conclusively decided on the limitation issue.
Dates and deadlines requiring review
Use this checklist to organize the dates in your file. It is a document-review aid — not a deadline calculator, and not a statement that every claimant has the same limitation period.
Date disability began
When you stopped working or first became unable to meet the policy’s disability definition.
Date benefits were applied for
Application or claim-submission date, including any forms sent by you, your employer, or your physician.
Date of initial denial
The decision date on the denial letter, not only the date you opened the email or mail.
Dates of appeal correspondence
Any appeal submissions, insurer acknowledgements, information requests, and follow-up decisions.
Date of any final denial
If the insurer issued a later letter maintaining or finalizing the denial after review.
Policy-based deadlines
Deadlines or notice requirements stated in the policy or booklet — wording varies by contract.
Potential statutory limitation issues
Ontario limitation questions can be fact-specific. Do not assume a single universal period applies to every claim.
Important: The applicable deadline and starting date can be fact-specific. They should be reviewed using the actual policy wording and correspondence. Do not assume every Ontario LTD claimant has exactly two years from a single common date.
Evidence that may matter
Diagnosis alone rarely decides an LTD dispute. Insurers and reviewers usually need to understand function: what the job requires, and what you can sustainably do.
Medical diagnosis and treatment
Diagnoses, specialist involvement, medications, therapy, imaging, and the clinical course over time.
Functional restrictions and limitations
What you can and cannot sustainably do: sitting, standing, lifting, concentration, attendance, pace, and recovery after activity.
Occupational duties
The real demands of the job — physical, cognitive, scheduling, travel, productivity, and safety requirements.
Cognitive and psychological demands
Memory, focus, emotional regulation, interpersonal demands, and stress tolerance where mental health or cognitive symptoms are involved.
Treatment history and compliance
What care was recommended, what was tried, barriers to care, and documented reasons for any gaps.
Failed return-to-work evidence
Attempts at modified duties, graduated returns, or rehabilitation that could not be sustained.
Third-party observations
Employer notes, family observations, or other collateral information where appropriate and available.
Mistakes to avoid
These are practical caution points, not predictions about any one claim.
- Sending a rushed appeal without first understanding the insurer’s stated reasoning.
- Relying only on a short doctor’s note that restates a diagnosis without functional detail.
- Missing insurer correspondence or information requests.
- Posting social-media content that can be taken out of context.
- Stopping treatment without documented reasons.
- Assuming the employer or insurer is protecting your legal interests.
What a lawyer reviews in a case review
A free case review looks at the documents that usually drive an Ontario LTD denial — and at the options those documents leave open.
- Policy wording and the disability definition applied
- Denial correspondence and any appeal letters
- Medical and treatment records
- Job demands and occupational evidence
- The insurer’s claim file, where available
- Surveillance, independent assessments, or vocational reports
- Key dates and potential limitation issues
- Available appeal or litigation options in light of the file
Our intake team will call you within one business day. No fee unless we recover compensation for you. Our fee is up to 33% of the amount recovered, confirmed in writing before we begin work.
Insurer-specific guidance
When insurer pages are published, they will appear here.
Frequently asked questions
- Can an LTD denial be challenged?
- Often, yes. A denial letter reflects the insurer’s decision at a point in time. Whether the decision can be challenged depends on the policy wording, the medical and functional evidence, the reasons given, and the options still available under the policy and Ontario law. A case review looks at those materials before recommending next steps.
- Should I appeal directly to the insurer?
- An internal appeal can be useful when new evidence is realistically available or when the insurer appears to have overlooked existing evidence. It is not automatically the best or only path. The appeal wording, timelines, and effect on other rights should be reviewed before you assume an appeal preserves every option.
- What if my doctor says I cannot work?
- A treating physician’s opinion is important, but insurers often weigh functional evidence, occupational demands, and their own assessments as well. Short notes that only restate a diagnosis are usually less helpful than records that explain concrete restrictions and why those restrictions prevent the required work.
- Can the insurer rely on surveillance?
- Insurers sometimes rely on surveillance or social-media material. Isolated activity does not necessarily mean a claimant can sustain the demands of an occupation. Context, frequency, and functional limits still matter and should be reviewed with the rest of the file.
- What documents should I collect?
- Start with the full denial letter, the policy or benefits booklet, claim forms, medical and treatment records, job description or duty list, and any appeal or rehabilitation correspondence. If the insurer has already built a claim file, requesting that file can also help a reviewer see what the decision was based on.
- How are legal fees handled?
- No fee unless we recover compensation for you. Fee is a percentage of the amount recovered, confirmed in writing before we begin work.
Sources & citations
- Limitations Act, 2002 — Limitations Act, 2002, S.O. 2002, c. 24, Sched. B, ss. 4, 5, 15 and 22 (basic limitation period, discoverability, ultimate limitation, and agreements). View source
General Ontario statutory framework. Application to a particular LTD file is fact-specific.
- Kassburg v. Sun Life Assurance Company of Canada — 2014 ONCA 922 (Court of Appeal for Ontario). Appeal and cross-appeal dismissed; contractual one-year provision not enforceable on the wording and documents before the Court; ambiguity and s. 22 business-agreement analysis addressed. View source
Does not establish current insurer forms or a universal contractual rule.
- Thompson v. Sun Life Assurance Company of Canada — 2015 ONCA 162 (Court of Appeal for Ontario). Appeal dismissed; motion judge had not completed the s. 22 analysis required to enforce a contractual one-year provision; appeal dismissed on a separate policy-eligibility ground. View source
Not a claimant victory on limitation; not a universal start-date rule.
- Clarke v. Sun Life Assurance Co. of Canada — 2020 ONCA 11 (Court of Appeal for Ontario). Appeal allowed in part; summary-judgment determination set aside; fuller factual record required for appropriate-means discoverability and the informal appeal process; remitted rather than finally decided on limitation. View source
Does not mean an informal appeal always suspends a limitation period.
- Contingency fee disclosure — No fee unless we recover compensation for you. Our fee is up to 33% of the amount recovered, confirmed in writing before we begin work. A written contingency fee agreement is required under Ontario rules before work begins.
Related reading
- LTD claims guideA plain-language guide to how long-term disability claims work in Ontario — group and individual policies, own-occupation and any-occupation periods, denials, terminations, and when legal advice may help.
- Change of definitionMany Ontario LTD policies shift disability definitions around the 24-month mark — timing depends on the policy.
- Terminated benefitsBenefits may stop after a review, surveillance, return-to-work assessment, or definition change.
- LTD lawsuitWhat litigation against an LTD insurer actually involves — steps, evidence, costs, and timelines.
- FeesLearn how contingency fees, a free case review and disbursements work for Ontario long-term disability claims. Our fee is up to 33% of the amount recovered.
- AboutLearn about Ontario Long-Term Disability Lawyers, our insurer-side experience and how our legal team helps with denied or terminated disability benefits across Ontario.