Disability Claims & Health Conditions

In this post, I will talk about a common question I get from potential clients. People with conditions like Long COVID, brain fog, depression and injuries – conditions for which there are no clear-cut scientific tests to determine a diagnosis – want to know how these types of conditions impact their entitlement to claim and receive disability benefits. In response, I tell them that, in order to receive disability benefits, the person must satisfy the definition of disability contained in the policy. The question is, whatever the condition, does it meet the definition of disability contained in the policy?

If you or a loved one has had a disability insurance or life insurance claim denied, you might find this article helpful in explaining your options. I will answer some common and frequently asked questions (FAQs) about disability claims.

If you’d like more information or to talk about your claim, please contact me at JoeyPollock.com.

Who am I, and how can I help you?

I am here to do my very best to assist you in obtaining your benefits. I want to help alleviate your stress and get you the benefits to which you may be entitled. My job, as I see it, is to take over your burden, stress and anxiety. With over 38 years of legal experience, including over 30 working on disability and life insurance claims, I have the experience to try to get you your benefits.

What kind of cases do I take on?

My specialty is working with people who have had their short-term and long-term disability benefits or life insurance claims denied. Because I focus on these types of claims, I do not take on any cases with Worker’s Compensation (WCB), Canadian Armed Forces (CAF), Canada Pension Plan (CPP) or Manitoba Public Insurance (MPI).

FAQs on Disability Claims and Health Conditions

Does it matter what my health condition is?

Generally speaking, a person is entitled to disability benefits if, because of illness or injury, the person cannot perform the duties of their own job for the first 24 months and are then unable to perform the duties of any job thereafter. Many potential clients ask if they are entitled to benefits for conditions such as brain fog from cancer treatments, depression and Long COVID – conditions for which there are no clear-cut scientific tests to determine a diagnosis. I tell them that, if they can establish that brain fog from cancer treatments, depression or Long COVID, is considered an illness which renders them disabled under their policy, they are entitled to benefits, just the same as someone who has a condition which can be diagnosed by a blood test, MRI, or X-ray.

What conditions automatically qualify you for disability?

In Canada, there is no pre-defined list of conditions that automatically qualify for disability. Entitlement to disability benefits depends on whether you suffer from an illness or accident. In other words, does that illness or accident prevent you from performing the duties of your own job for the first 24 months, and then from any job thereafter? If the answer if yes, it matters not what that condition is.

How much money do you get on disability benefits?

The amount of money you receive depends on the wording contained in your policy. Generally, disability benefits are calculated based on 60-70% of your pre-disability income. A review of the applicable policy will easily answer that question.

What qualifies as a disability?

There is a difference between a disability and a person who qualifies for disability benefits. As an example, a person with MS who is confined to a wheelchair would have a disability, but may not be entitled to disability benefits. If that person’s occupation is non-physical in nature, the fact they have a disability does not mean they are unable to work at a non-physical job like an accountant or psychologist. The issue is not whether the person has a disability, but rather whether the person has an illness or injury which prevent them from working at their own job, or at any job.

How does the law define a disability?

There is no statutory law that defines a disability in the context of a group or private disability policy. Disability is a contractual definition contained in the group or private disability policy. To qualify for disability benefits, an applicant must provide evidence that they meet the definition of disability contained in that particular policy.

Process for filing a claim

When a person’s disability benefits have been declined or terminated, they can sue the insurance company by filing a statement of claim in court.

Statement of claim

The statement of claim is a document outlining your allegations against the insurance company. It includes the facts and the legal remedy you are seeking. Think of it as your story, explaining why you believe the insurance company is at fault, and what you hope to achieve through legal action.

What is Discovery?

Discovery is the phase where both parties – the plaintiff and the defendant – exchange information relevant to the case. This includes documents, records, or any evidence that the parties intend to rely upon in court. It allows each side to “discover” the position of the other party so that there are no surprises.

Documentary discovery

Documentary discovery refers to written or recorded materials that can be presented in court to support your case. These include documents such as contracts, emails, or medical records. This is evidence you will be relying upon to prove your claim in court.

Oral Discovery and Oral Evidence

Oral discovery takes place in a lawyer’s office, whereby each side gets an opportunity to examine (“discover”) the other side. The lawyer for the insurance company will examine the plaintiff, and the plaintiff’s lawyer will examine a representative of the insurance company. The evidence is taken under oath before a court reporter and transcripts of the evidence are then created by the court reporter.

At trial, evidence of witnesses called by both sides is given under oath and recorded by a court reporter. The witnesses may be called to testify about specific events or circumstances. This evidence, combined with documentary evidence, helps build a comprehensive picture of the case. Your doctors and members of your medical support team may also be called to give evidence at trial.

Settlement

Most civil actions are settled before trial. A settlement is an agreement reached between the parties which involves both sides compromising on certain terms and conditions in order to resolve the dispute. Settlements can save time and costs associated with a trial and avoid the uncertainties of a trial. If the lawyers are unable to resolve the case on their own, mediation is an option. In most cases, mediations result in a successful settlement. If the parties cannot resolve the case on their own, or with the assistance of a mediator, then they proceed to trial. A judge will then determine if the plaintiff is or is not disabled in accordance with the terms and conditions of the policy.

Mediation

Mediation is a process where a neutral third party attempts to help facilitate discussions between the parties to reach a resolution. It is a less formal process than a trial, and provides an opportunity for open communications and negotiations. In Manitoba, mediations generally take place before a Manitoba Court of King’s Bench judge. That judge has no power to force a settlement or make any ruling. Their presence is to simply assist the parties in trying to settle the case.

Trial

A trial is a formal legal proceeding where both parties present their case before a judge. It involves presenting documentary evidence, examining witnesses, and making legal arguments. Ultimately, the judge will determine if one is or is not entitled to disability benefits. Unlike a settlement, which guarantees certainty for the parties, there is no certainty in proceeding to trial. At trial, the court – not the parties – decides the outcome.

Conclusion

I see my job as assuming and relieving you of the burden, stress and anxiety you are experiencing as a result of the termination or denial of your claim. While I cannot guarantee that you will receive disability benefits, I will do everything I can to try to assist you in doing so.

In this post, I have answered some key questions about disability claims. I have also outlined the process for making a claim your claim has been terminated or denied by the insurance company.

If you have had a life or disability claim denied, please feel free to contact me today at JoeyPollock.com!

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joseph Pollock, Winnipeg Disability Lawyer

About Joseph A. Pollock

Joseph (Joey) Pollock is a Winnipeg-based attorney with over 35 years of legal experience – 25 of those years dealing with disability and life insurance claims.