Mental Health and LTD Claims: a Complete Documentation Strategy for Ontario Workers

Ever since the letter arrived from your Long Term Disability company notifying you that, in a few short weeks, the financial support you had been receiving is going to be cut off, you’ve felt paralyzed by panic.

The only hope being offered involves doing the impossible –‘proving’ what can’t be ‘proved.’ Sure, there are plenty of physical symptoms to be described — the chronic fatigue, heart palpitations, the weight gain (your doctors have mentioned tan early onset of diabetes), the breathing problems and the almost-constant upset stomach.

Still, you know there’s no blood test to demonstrate the extent of the almost-daily bouts of depression and anxiety, yet those have become an all-too-real part of your life. The therapists you’ve visited have used the term OCD and even prescribed medications related to bipolar disorder.

But there’s no x-ray to provide visual proof of why you came to find the work environment so terrorizing.  

Related to the 24-month termination of benefits notice you received from your Ontario long term disability insurance company, you’re scheduled for some Independent Medical Examinations.  Just the thought of all new tests and interviews causes you fear and anxiety.

While many of your problems are invisible from the outside, your regular therapists have come to understand your fears and sometimes strange behaviors. 

Outwardly, you’re looking better, your neighbors and one or two of your remaining friends tell you, but you realize that getting ‘better’ is not really happening for you.

LTD decisions focus on functional limits, not labels. For anxiety, depression, PTSD and similar conditions, document how symptoms affect reliability, attendance, pace, focus, and stress tolerance. Use consistent clinical notes, treatment adherence, standardized scales, a ‘typical day’ narrative, and employer evidence. Close gaps early to reduce denials and protect benefits at 24 months.

Can mental health conditions qualify for LTD benefits in Ontario, Canada?  

First, know that you’re not alone. In fact, as Benefits Canada points out, more than a third of disability claims under Canadian employer-sponsored benefits plans in 2022 were due to mental health reasons. Long term Disability policies in Ontario do cover these conditions if they prevent an insured from performing the essential duties of the job.

Yet, as you suspected, many individuals who rely on disability benefit coverage are unfairly denied by their insurers precisely because mental illness is more difficult to prove.

It is important to understand that qualifying for long-term disability benefits depends less on having any specific physical or mental condition, but on whether that condition not only currently prevents you — but is likely to continue preventing you, for the foreseeable future — from performing duties at any job for which you are reasonably suited.

In judging whether you are, in fact, capable of performing job duties, the considerations include:

• Reliability – will an employer be able to count on you to get the job done?
• Attendance – will an employer be able to count on you to show up, ready for work, on a regular basis?
• Pace – will you be able to keep up with the work flow as part of a team?
• Stress tolerance – when inevitable frustrations, delays, and problems arise, will you be able to handle the situation calmly and responsibly?   
• Memory – will you be able to remember procedures needed to needed to complete job-related tasks?
• Interaction with other employees – are you going to get along with co-workers and supervisors?

Yet many individuals who rely on disability benefit coverage are unfairly denied by their insurers precisely because mental illness is more difficult to prove.

How will those Independent Medical Examinations come into play?

An IME (Independent Medical Examination) is conducted by doctors and therapists chosen by the insurance company to evaluate your condition and decide if the treatments recommended by your own doctors are necessary and appropriate.

Up until now, you have been eligible for benefits because you have been unable to perform the duties of your own occupation. But starting from the 24-month mark, you will be entitled to receive benefits only if it is proven that you are unable to work at any occupation for which you qualify based on your level of education, training, and work experience.

The stated purpose of an IME is to provide ‘neutral’ answers to all the questions listed above. In reality, the insurance company may use the IME results as justification for denying or reducing benefits to an insured.

Building your case to keep your benefits: a step-by-step documentation strategy

Being asked to ‘prove what can’t be prove’ has you overwhelmed. You’re exhausted before you even begin the fight — between managing your own health, the endless paperwork, and the overwhelming financial concerns, you feel you’re at a breaking point. But know this:

You’re not going to let this challenge break you. You can build your case in five steps:

• Step One: Assemble medical evidence

Contact each doctor, psychiatrist, and therapist you’ve seen for an Updated report.  Don’t accept vague generalities, such as “doing well” or “stable”. Ask each respondent to give an opinion about how ready you are — or are not — to handle the duties of a full-time job.

• Step Two: Assemble a report on your medications

What medications have been prescribed? What have been the side effects of each?  Have there been barriers (needing to get on a waiting list or excessive cost)?

• Step Three: Create a ” typical day” description

Starting with mornings, describe your everyday “mood life” — what helps you get going?  What seems to over-stimulate you? What things trigger a “meltdown” or “crash”? How long does it take to you to recover? What tasks are sometimes forgotten?

• Step Four: Reconstruct the six months before you were forced to quit working

Organize the paperwork from the last few months on the job, including warnings from your supervisor, performance reviews, modifications to your job responsibilities, and recommendations for treatment.

• Step Five: Study the denial letter and decide between filing an internal appeal or proceeding directly to a lawsuit

Internal appeal windows vary by insurer, often around 180 days from the decision letter date. Litigation timelines are different. Get case-specific advice from a disability rights attorney before choosing your next step.