How Disability Insurance Claims Work

Employees are usually given a benefits booklet, which is a summary. The document that governs is the **group master policy** or, for individual coverage, the full policy. Request it in writing — you are generally entitled to it, and its definitions decide your claim.

Read for four things: the definition of disability, the elimination period, the offsets, and any limitation provision.

Most policies start with **own occupation** — you are disabled if you cannot perform the substantial duties of your own job. After a defined period, commonly two years, many switch to **any occupation**, meaning you must be unable to do any work you are reasonably suited to by training, education and experience.

That switch is the most common cause of terminations, and it is why benefits often stop around the two-year mark despite no change in your condition. Check when yours changes, because it lets you prepare evidence for a harder test rather than being surprised by it.

An **elimination period** is the waiting time before benefits begin — often covered by short-term disability or sick leave. Coordination gaps between STD ending and LTD starting are common and worth watching.

**Offsets** reduce your LTD payment by other income: CPP disability, workers' compensation, auto accident benefits, and sometimes employment income. This surprises claimants who are told to apply for CPP-D and then find their LTD reduced by roughly the same amount. It is usually still worth applying, because CPP-D continues if LTD ends.

**Insufficient objective evidence** — answered with functional evidence: what you cannot sustain, for how long, and why. Diagnosis alone rarely decides a claim; function does. **Pre-existing condition exclusions** — answered by the policy wording and the timing of symptoms and treatment. **Definition not met** — answered by evidence measured against the applicable test, own or any occupation.

Insurers also rely on independent medical examinations, surveillance and social media. Consistency between what you report to each physician, your treatment history and your actual activity is the strongest thing in your control.

Because this is contract law, there is no tribunal — you sue. The limitation period typically runs from the denial or termination, and **the policy can shorten the ordinary statutory period contractually**. Internal appeals do not pause it.

So the order is: find out your deadline, then decide whether to appeal internally. Doing it the other way round is the single most damaging error in this area. Where handling has been egregious — unexplained delay, shifting reasons, ignoring treating physicians — Canadian courts have awarded aggravated and punitive damages beyond the benefits owed.