The term “total disability” is generally found in most Long-Term Disability (LTD) insurance policies. When applying for LTD benefits, this term represents the first, of potentially many hurdles, that applicants must get over before being deemed eligible. In order to receive benefits, the insured must meet the threshold of “total disability”. In the context of LTD coverage, “total disability” is not normally interpreted according to the every day use of the words. Individuals applying for LTD benefits do not necessarily have to be totally disabled, that is to mean, completely unable to perform any physical function. Instead, the term “total disability” is ascribed its own meaning by the LTD policy as well as the courts.
Many LTD policies define “total disability” as the insured’s inability to perform the essential duties of his or her “own job”, for a period of time, and the essential duties of “any job” thereafter. For more detail regarding the meaning of “own job” and “any job”, and how this can affect your LTD benefits, please see our blog post on the subject. Similarly, the courts have adopted their own definition with regards to the meaning of “total disability” in the context of LTD insurance. The Supreme Court of Canada, in Paul Revere Life Insurance v. Sucharov, defined in the following way:
“the test of total disability is satisfied when the circumstances are such that a reasonable man would recognize that he should not engage in certain activity even though he literally is not physically unable to do so. In other words, total disability does not mean absolute physical inability to transact any kind of business pertaining to one’s occupation, but rather that there is a total disability if the insured’s injuries are such that common care and prudence require him to desist from his business or occupation in order to effectuate a cure; hence, if the condition of the insured is such that in order to effect a cure or prolongation of life, common care and prudence will require that he cease all work, he is totally disabled within the meaning of health or accident insurance policies”.
When attempting to claim LTD benefits, the extent of your disability, and whether it meets the definition of “total disability”, is one of the most common issues raised by insurers in order to deny benefits. You may find that you have been denied for benefits even if your family doctor or treating specialists agree that you are unable to work. Your insurer may raise issues regarding the level of expertise of those treating your medical condition, or may argue that your treating specialists is not familiar enough with your case to determine your ability to continue working. It is not uncommon for these and many other challenges to be raised by insurance companies with regards to the medical evidence introduced by those claiming LTD benefits. Because of this, you may find that the question of whether you are unable to work has become a legal matter, rather than a medical one. In such cases it is important to consult an LTD lawyer, who can help you assess your medical evidence in the legal context, and advise on your possible avenues to receive LTD benefits from your insurance company.
