Claim Appeal Process

A guide to help with your LTD claim appeal

The Plan Administrator, Canadian Benefits Consulting Group is available to answer any questions you have regarding the appeal process. Additionally, it is always best to reach out to your case manager if you require any assistance in clarifying your claims decisions and next steps.
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In general, the appeal process is:

  • 3 levels of appeal
    • Appeal 1 is handled by the Case Manager
    • Appeal 2 is reviewed by the Case Manager. If the case manager is going to maintain the claims decision, the appeal will be reviewed by a Sr. Case Manager for a secondary review.
    • Appeal 3 is handled at head office by an Appeals Specialist
  • Advise Canada Life of Intent to Appeal in writing within 90 days
  • Appeal within a 12-month time frame from the date of the declination letter or call.
  • No further medical information will be reviewed one year post claim declination/ termination.

During an appeal, the onus to provide and pay for additional medical information is the responsibility of the Member. The standard turn around time is 10 – 30 business days.

IMPORANT: you must submit your appeal and applicable information within the time specific time frame as set out by Canada Life.

Step 1: Deciding if you will appeal

If you disagree with the decision on your claim, you have the option to submit an appeal. We recommend notifying the plan administrator and case manager that you will be disputing your claim.

When deciding to appeal, always refer the letter provided by the Case Manager. The Case Manager’s letter will outline the reasons for the claims decision and any important details that apply to your claim, along with recommendations for your appeal.

Step 2: Review what additional information could be sent as part of your appeal

It is recommended to review your denial or termination letter with your appropriate treatment providers, so they understand the reasons for your claim decision, and how to help provide you with the appropriate supporting information for your appeal.

Examples of supporting medical documents:

  • Clinical notes from the applicable treatment providers
  • Narrative reports
  • Specialist Consultation reports
  • Test results of investigative reports
  • Any other medical document that helps substantiate your disability

Other information that can assist with an appeal due to contractual eligibility:

  • Additional coverage documentation from Employer/ Plan Administrator/ Union
  • An explanation or reasoning as to why the claim was late filed.
  • Provide a copy of your claim file from an MVA or Worker’s Compensation Board
  • Information regarding your training, education, and experience as it related to performing alternate occupations.

Step 3: Notify Canada Life in writing you would like reconsideration of your claim

In writing explain your reasons as to why you disagree with the decision made on your claim and would like reconsideration.

  • How your medical conditions prevents you from working your own or any occupation.
  • Why you feel the contract provision applied to your claim is incorrect or should not have been applied in your situation.
  • Any additional details or explanation about you, your medical condition or inability to work that you would like Canada Life to be aware of.
  • If you feel there is no additional information you can provide, explain the reason why you would like your claim reconsidered without submitting further information.
  • Include any supporting documents as part of your appeal.

Have further questions?

Please contact:

Laura Barlett
Account Manager
Canadian Benefits Consulting Group
or 416 488 7755 ext 245.