Why Insurers Deny LTD Claims

The reasons why insurers deny LTD claims come from a short list. A denial letter reads like a medical conclusion, but each stated reason traces back to a clause in the policy or to a gap in the paperwork. Knowing which reason you were given tells you what the file needs next, and it sets the issue in any lawsuit that follows.

Why Insurers Deny LTD Claims Most Often

The definition of disability in the policy is the ground cited most often. The insurer accepts that you have a condition and decides the condition does not stop you from doing the work the policy names. Which work it names depends on the stage of the claim, set out in own occupation and any occupation. Denials around the 24-month mark almost always take this form, because the test itself changes there.

The Medical File Lacks Objective Findings

Insurers write that restrictions are self-reported, or that objective findings do not support the reported level of impairment. Conditions that do not appear on imaging attract this reason most often: chronic pain, depression, post-concussion symptoms, fibromyalgia. No rule of law requires an imaging finding before a disability is real. The reason is answerable with the right treating-physician material, described in the medical evidence chapter.

Late Notice or Late Proof of Claim

Group policies set deadlines for notifying the insurer and filing proof of claim, counted from the start of the disability rather than from the denial. A late filing is often curable, and insurers rarely rest on it alone, but it appears in letters as a supporting reason.

An Exclusion or a Pre-Existing Condition

Most group policies exclude conditions treated during a defined window before coverage began, which catches employees who claim in their first year. Other clauses exclude self-inflicted injury or limit mental-health claims to a fixed number of months of payment. An exclusion is only as wide as its wording, and the insurer has to bring your facts inside it.

Non-Compliance with the Insurer’s Requirements

Missing an independent medical examination or failing to return a requested form gives the insurer a procedural reason to stop payment. Policies also require appropriate treatment by a qualified physician, and an insurer reads a gap in treatment as evidence that the condition improved. Surveillance is often ordered at the same moment, covered in the surveillance chapter.

What the Stated Reason Tells You

Read the letter for what it claims rather than for its tone. The reason it gives is the ground the insurer will defend, and the letter starts a court deadline that an internal appeal does not pause. The firm reads a denial letter against the master policy before giving any opinion, as described on the long-term disability lawyer page. Decided cases interpreting these clauses are free to read on CanLII.