Long term disability claims in Ontario

A long term disability claim in Ontario is not a personal injury claim. It is a contract claim against an insurer, nobody has to have been at fault, and the definition that decides it is written in the policy rather than in any statute.

About this work

What does the policy definition actually decide?

Almost everything. There is no statutory test of disability in this area, so entitlement is measured against words the insurer drafted, and those words differ between policies in ways that change outcomes.

The common structure is two stages. For an initial period, often around the first two years of benefits, the test is whether you can perform the essential duties of your own occupation. After that the test usually changes to whether you can perform the duties of any occupation for which you are reasonably suited by education, training or experience.

That switch is where a great many claims are terminated, and it is predictable. A claimant receiving benefits under an own occupation test should know the date the definition changes, because the evidence needed to hold the claim after it is different and takes time to build.

Any occupation does not mean any job at all. It is qualified by suitability and, in most wordings, by a comparable level of earnings. A surgeon is not expected to take work as a greeter, and the argument about what counts as reasonably suited is a real one.

Written by the firm. Pending review by Kapil Rathod, Barrister and Solicitor, Law Society of Ontario licence 77122E.

The two clocks

There is a limitation period, and the policy may set a shorter one

This is the single most dangerous feature of these claims, and it is the reason a denial letter should be brought in rather than filed away while an internal appeal runs.

  1. Two years from discovery, under the statute

    The basic limitation period bars a proceeding after the second anniversary of the day the claim was discovered. On a denied disability claim that is usually the day you were told, in clear terms, that benefits were being refused or stopped.

  2. And the policy frequently contains its own

    Group and individual policies commonly include a contractual limitation clause, and it can be shorter than the statutory period or run from a different event. The policy has to be read alongside the statute rather than instead of it.

  3. An internal appeal does not stop either clock

    Insurers offer them, they are worth using, and they do not pause a limitation period unless the insurer agrees in writing to pause it. People lose good claims by appealing politely for eighteen months.

  4. So the denial letter is the document that matters

    Its date, its wording, and whether it is a final decision or a request for more information are what the limitation argument turns on. Bring it in the week it arrives.

Side by side

How is this different from an injury claim?

6 points of difference

People arrive expecting the framework that applies to a car accident, and almost none of it transfers.

A long term disability claim

Who you claim against
Your own insurer, or the group insurer through your employer
Does anyone have to be at fault
No. It is a contract claim
What decides entitlement
The definition of disability written in the policy
Is there a threshold or deductible
No, but there are offsets for other benefits received
The limitation period
Two years from discovery, and possibly a shorter one in the policy
What usually decides the case
Medical evidence measured against the policy wording

A personal injury claim

Who you claim against
The person or company at fault
Does anyone have to be at fault
Yes. Negligence has to be established
What decides entitlement
Liability, causation and the extent of the injury
Is there a threshold or deductible
On motor vehicle claims, yes: a threshold and a deductible
The limitation period
Two years from discovery
What usually decides the case
Medical evidence measured against the statutory threshold

The route

How does the process run?

5 stages, each with its own clock

Long term disability is governed by the policy rather than by a statute, so the provisions below are the ones that set the outside limits. Everything else comes from the wording of the contract, and no two policies are identical.

01

Two years from discovery

Limitations Act, 2002 s. 4, 5

The basic limitation period bars a proceeding after the second anniversary of the day the claim was discovered, with the discovery test in section 5 and a presumption that discovery happened on the day of the act or omission.

02

Read the policy's own limitation clause

The policy

Many policies contain one. It may be shorter than two years, and it may run from a different trigger such as the date proof of claim was due rather than the date of denial.

03

Find out which definition of disability applies

The policy

Most policies pay on an own occupation basis for an initial period, commonly around two years, and then switch to an any occupation test. The switch is when a large share of claims are terminated, and it is a foreseeable date rather than a surprise.

04

Check what is offset

The policy

Policies reduce benefits by amounts received from other sources, which can include Canada Pension Plan disability, workplace insurance and accident benefits. An award elsewhere can reduce the disability benefit rather than adding to it.

05

And keep treating

Evidence

Entitlement is proved from the treating record over time rather than from a single assessment. A claimant who stops attending because nothing is helping produces a file that reads as though the condition resolved.

Before the meeting

What to bring to the first meeting

6 things to bring

Bring what you have and say what is missing. A meeting with the papers in front of it settles in one sitting what two telephone calls will not.

  • ✓The denial or termination letter, and the date it arrived
  • ✓The policy or booklet, if you can get it from your employer
  • ✓Every letter from the insurer, in date order
  • ✓The names of everyone treating you, and for what
  • ✓Your job description, and what you can no longer do in it
  • ✓Anything you receive from CPP disability, workplace insurance or an insurer

Our approach

A clear path forward

The same four steps on every matter, whether it is a refusal at the Federal Court or a ticket at the Provincial Offences court.

Book a consultation
01

Understand

We take the full history and read the documents before offering an opinion. Most bad advice comes from acting on half the facts.

02

Assess

You get a candid read on strength, timeline and cost, including when the honest answer is that you do not need to hire anyone.

03

Act

We prepare the application, the defence or the appeal properly the first time, because fixing a weak record later is harder and dearer.

04

Report

You hear from us at each stage, and you hear what a wait actually means rather than a date chosen to sound better.

Reported decisions

What has this work produced?

7 allowed of 22 reported since 2023

Public judgments of the Federal Court with Kapil Rathod as counsel of record, each checkable by citation on the court's own site. The rest were dismissed and are listed with these ones.

All case outcomes, including the client accounts

Where to go next

A long term disability claim in Ontario is a contract claim decided on the policy wording and the treating record.

Two clocks run, one statutory and one possibly written into the policy, and an internal appeal stops neither of them.

Car accident claimsThe personal injury practiceA Superior Court claim for breach of contractBook a consultation

Common questions

What do people ask about long term disability?

8 answered here

Written to be read once and acted on rather than to be rung about. Each answer is complete where the law allows a complete answer.

Why are these claims denied?

Usually on the medical evidence rather than on bad faith, and usually because the file does not say what the claimant assumes it says.

The commonest reason is a gap between the diagnosis and the functional limitation. A diagnosis establishes a condition. What a policy asks is what you cannot do, and a medical record that records a condition without recording its effect on specific work tasks does not answer the question being asked.

The second is inconsistency, real or apparent. Surveillance, social media, and a physician's note describing improvement can all be used to suggest the limitation is less than claimed. Some of that is unfair and some of it is a genuine problem with how the file was documented.

The third is subjective conditions. Chronic pain, fibromyalgia, depression and anxiety are frequent grounds of denial precisely because there is no scan that settles them, and they are also among the most common causes of long term disability. Those claims are won on consistency and on treating records over time rather than on any single document.

What happens after a denial?

Two routes, and they are not alternatives in the way insurers present them. An internal appeal is offered by most insurers and is worth using where there is new medical evidence to put forward. It is quick, it costs nothing, and it occasionally works.

What it does not do is stop time running. Unless the insurer agrees in writing that the limitation period is suspended, the clock runs through the appeal, and a claimant who appeals twice over eighteen months can find the claim is out of time before anybody has read the policy's own limitation clause.

The second route is a claim in the Superior Court for breach of contract. That is the route that produces settlements, and most of these matters resolve without trial once the medical record and the policy wording are properly put together.

This work is normally done on a contingency basis, so the fee comes out of the recovery. The agreement has to be in writing and it has to state the percentage, and disbursements such as medical records and expert reports are separate from the fee and should be explained before anything is signed.

What makes the difference to the outcome?

The treating record, built over time and specific about function. A note saying the patient reports ongoing pain is worth far less than one recording what they can no longer do, for how long, and with what effect on the particular duties of their job.

That is something a claimant can influence. Attending appointments, describing limitations in functional terms, and making sure the family physician understands what the policy actually asks are all within reach, and they matter more than any expert report obtained later.

Continuity matters too. Gaps in treatment are read as improvement, whatever the reason for them, and a claimant who stops attending because nothing is helping should say that to somebody who will write it down.

And the policy itself needs reading early. The definition, the limitation clause, the offsets and the proof of claim requirements are all in a document most claimants have never seen, because it sits with an employer's benefits administrator rather than with them.

How long do I have to sue my disability insurer?

Two years from the day the claim was discovered under section 4 of the Limitations Act, 2002, which on a denied claim is usually the day you were clearly told benefits were refused or stopped. The policy may also contain its own limitation clause, and it can be shorter, so both have to be read together.

Does an internal appeal pause the deadline?

No, not unless the insurer agrees in writing that it does. Appeals are worth using where there is new medical evidence, but the limitation period runs throughout, and claims are lost by appealing politely for a year and a half.

My benefits stopped after two years even though nothing changed. Why?

Almost certainly because the policy definition changed. Most policies test the first period against your own occupation and then switch to any occupation for which you are reasonably suited by education, training or experience. The switch date is predictable and the evidence needed afterwards is different.

They say my condition is subjective. Is that fatal?

No. Chronic pain, fibromyalgia, depression and anxiety are among the most common causes of long term disability and among the most commonly denied. Those claims are proved from consistent treating records over time rather than from any single test result.

What does it cost to bring a claim?

This work is normally done on a contingency basis, so the fee comes out of the recovery and there is nothing to pay up front. The agreement must be in writing and must state the percentage. Disbursements such as medical records and expert reports are separate and you are told what they are likely to run to before the retainer is signed.

Speak to someone this week

Bring the denial letter and the policy if you can get it. A long term disability claim in Ontario turns on the definition in that document and on when you were told.

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