---
title: "Long-term disability denied in Ontario: appeal, sue or both?"
date: 2026-09-29
author: "K&S"
url: https://cohenmurisonlaw.com/insights/long-term-disability-denied-ontario/
---

![](https://cohenmurisonlaw.com/wp-content/uploads/2026/10/insight-ltd-forms.webp)
 
 

Sep 29, 202610 min read

 

# Long-term disability denied in Ontario: appeal, sue or both?

 

LTD benefits denied or cut off in Ontario? How to read the letter, own vs any occupation, internal appeals vs suing, the 2-year limit and CPP offsets.

 

![](https://cohenmurisonlaw.com/wp-content/themes/cohen/assets/ben-sm.webp)
 **Benjamin Cohen-Murison**Lawyer · Law Society of Ontario, L.S.O. No. 89551C

 

In this article

1. [Start with the letter and the policy](#read-the-letter)
2. [Own occupation versus any occupation](#own-vs-any-occupation)
3. [Internal appeal or a lawsuit?](#appeal-or-sue)
4. [The two-year limitation period](#limitation-period)
5. [CPP disability benefits, offsets and the Social Security Tribunal](#cpp-disability)
6. [Surveillance and independent medical examinations](#surveillance-and-imes)
7. [What evidence matters most](#evidence)
8. [Common mistakes after a denial](#common-mistakes)
9. [What to bring to your lawyer](#what-to-bring)
10. [Common questions](#questions)
11. [Sources](#sources)

A letter from a disability insurer saying your long-term disability (LTD) claim is denied, or that your benefits will end on a certain date, can feel final. It usually is not. Most LTD benefits in Ontario come from a group policy through work, and a denial is the insurer's reading of that policy and your medical file. You can challenge it, but the route you pick and the dates you track matter more than most people expect. This guide explains how to read the letter, the own-occupation and any-occupation tests, whether to appeal internally or sue, the two-year limitation period, how Canada Pension Plan disability benefits fit in, and the evidence that tends to decide these cases.

## Start with the letter and the policy

Read the denial or termination letter slowly, and more than once. Look for four things:

- **The reason.** Is the insurer saying you were never disabled, that you have recovered, that you no longer meet a stricter definition, that you did not give it enough medical information, or that an exclusion (such as a pre-existing condition clause) applies?
- **The evidence it relied on.** Letters often name a file review by the insurer's own medical consultant, an independent medical examination, a functional assessment or surveillance.
- **The date benefits stop**, or the date the claim was refused.
- **What it offers next**, usually an internal appeal, with a deadline for sending more information.

Then get the documents the decision is based on. If your coverage is through a group plan, the insurer must, on request, give you a copy of your enrolment application and any evidence of insurability you provided, and must let you examine and receive a copy of the group policy itself (*Insurance Act*, s. 293(5)). The booklet your employer handed out is a summary, and the policy wording is what governs. Ask in writing for your complete claim file as well, including medical consultant reviews and any surveillance reports. Keep the envelope or email showing when the letter arrived.

## Own occupation versus any occupation

Many group LTD policies use two tests of disability, one after the other:

- **Own occupation.** For an initial period, often the first 24 months of benefits, you qualify if your condition prevents you from doing the essential duties of your own job.
- **Any occupation.** After that period, you must show you cannot do *any* occupation for which you are reasonably suited by education, training or experience. Policies word this differently, and some add an earnings test (for example, any job paying a set percentage of your pre-disability income).

The change from one test to the other is one of the most common points at which benefits are cut off. The insurer may send new forms, ask for updated reports and arrange a vocational or "transferable skills" analysis listing jobs it says you could do. If you are approaching that date, the time to prepare is before the letter arrives: make sure your doctors' reports speak to your ability to do any work, not just your old job.

Read your own policy's definition word for word. Small differences, such as "reasonably suited" versus "able to perform", or whether part-time work counts, can change the answer. Your lawyer will compare the definition to the jobs the insurer has identified and to your real limitations.

## Internal appeal or a lawsuit?

Most insurers offer one or more levels of internal appeal. An internal appeal is a request that the same insurer look at its decision again. It costs nothing, and it can work when the denial was based on a missing document that you can now supply. But it has real limits: the insurer decides its own appeal, there is no independent judge, and while you wait, time is running on the limitation period.

A lawsuit is an action in court for breach of the insurance contract. As a member of a group plan you can sue the insurer in your own name, even though your employer holds the policy (*Insurance Act*, s. 318). In court, the insurer must produce its documents, its witnesses can be questioned under oath, and a judge, not the insurer, decides whether you meet the policy definition.

| Question | Internal appeal | Lawsuit |
| --- | --- | --- |
| Who decides? | The insurer | A judge (or jury) |
| Does it stop the limitation clock? | Not reliably | Yes, once the claim is issued |
| Can you see the insurer's whole file? | Only what it chooses to share | Yes, through documentary disclosure |
| Can you claim more than unpaid benefits? | No | Possibly, in some cases (see below) |

The two routes are not always either/or. Sometimes it makes sense to send a short, well-supported appeal while a lawsuit is prepared. What you should not do is send repeated appeals for months without a lawyer checking the limitation date.

## The two-year limitation period

In Ontario, a court proceeding generally must be started within two years of the day the claim was "discovered" (*Limitations Act, 2002*, s. 4). A claim is discovered when you knew, or a reasonable person in your circumstances ought to have known, that you suffered a loss caused by the other party and that a court proceeding would be an appropriate way to remedy it (s. 5(1)).

For LTD claims, the key question is which date starts the clock. In *Kassburg v. Sun Life Assurance Company of Canada*, 2014 ONCA 922, the Court of Appeal for Ontario upheld a finding that the claim was discovered when the insurer's denial became clear and unequivocal, which on those facts was when the insurer confirmed the final internal appeal had failed, rather than the date of the first denial letter. The Court stressed that this is essentially a question of fact. In other words, a different file with different letters can produce a different start date.

Some practical rules follow:

- **Count from the first denial letter.** Treat that date as the latest safe starting point until your lawyer has reviewed every letter. Relying on an appeal to move the date is a risk you do not need to take.
- **Check the policy for a shorter limit.** Some policies say you must sue within one year. In *Kassburg*, the policy's wording was too ambiguous to displace the statutory two years, and the Court added that a group disability policy bought for employees' personal benefit is not a "business agreement", the only kind of agreement that may shorten the period (s. 22(5)).
- **There is also an outer limit.** No proceeding may be started more than 15 years after the act or omission the claim is based on (s. 15(2)), although that period can be suspended in limited situations, such as incapacity (s. 15(4)).
- **Incapacity can pause the basic period.** The two years do not run while a person is incapable of starting a proceeding because of their physical, mental or psychological condition and has no litigation guardian (s. 7(1)). A person is presumed capable unless the contrary is proved (s. 7(2)), so do not rely on this without advice.

## CPP disability benefits, offsets and the Social Security Tribunal

Most group LTD policies require you to apply for Canada Pension Plan disability benefits (CPP-D) and reduce your LTD payments by the amount CPP pays. The offset comes from your policy, so read that clause. If CPP later approves you with a retroactive payment, the insurer will often claim back the overlapping amount. Set money aside rather than spend a lump sum that may already be owed.

CPP uses its own test, which is stricter than many "own occupation" definitions. A disability must be both **severe**, meaning you are incapable regularly of pursuing any substantially gainful occupation, and **prolonged**, meaning it is likely to be long continued and of indefinite duration or likely to result in death (*Canada Pension Plan*, s. 42(2)(a)). You cannot be deemed disabled earlier than 15 months before the date you apply (s. 42(2)(b)), so a late application can permanently lose months of benefits.

If CPP-D is refused, the deadlines are short:

1. **Reconsideration.** Ask the Minister to reconsider within 90 days after you are notified of the decision (*Canada Pension Plan*, s. 81(1)).
2. **Social Security Tribunal, General Division.** If reconsideration fails, appeal within 90 days after the decision is communicated to you. The Tribunal can allow more time, but never more than one year after that date (*Department of Employment and Social Development Act*, s. 52).
3. **Appeal Division.** A further appeal needs leave, which is granted only if you raise an arguable case of a legal, factual or procedural error, or present evidence the General Division did not have (s. 58.1).

A CPP-D refusal does not decide your LTD claim, and a CPP-D approval does not bind the insurer either. But each file is evidence in the other, so keep them consistent.

## Surveillance and independent medical examinations

Insurers often hire investigators to film claimants in public, and they review social media. A clip of you carrying groceries, or a holiday photo, may be presented as proof you can work. What matters is context: how long the activity lasted, what it cost you the next day, and whether it is consistent with what you told your doctors. In *Fidler v. Sun Life Assurance Co. of Canada*, 2006 SCC 30, an insurer ended benefits after surveillance, and the Supreme Court of Canada upheld damages for mental distress caused by the wrongful denial of disability benefits. That case does not mean every denial attracts extra damages, but it shows that how an insurer handles a claim can matter.

Policies usually let the insurer have you examined by a doctor or assessor it chooses. Attend, be on time, be accurate, and do not exaggerate or minimize. Write down afterwards how long the examination lasted and what tests were done, because reports sometimes describe a longer or more thorough assessment than took place.

Once a lawsuit is under way, the court can order a party whose physical or mental condition is in question to be examined by a health practitioner chosen by the other side (*Courts of Justice Act*, s. 105; *Rules of Civil Procedure*, r. 33). Surveillance becomes a document in the case. If the insurer claims privilege over surveillance and does not produce it at least 90 days before trial, it cannot use it at trial except to impeach a witness or with the judge's leave (r. 30.09).

## What evidence matters most

LTD cases are won or lost on the quality of the medical and functional evidence, not on the number of pages. The most useful records usually include:

- **Treating doctors' reports that address function**: what you cannot do, for how long, and why, tied to the policy definition. A note that simply says "patient is disabled" carries little weight.
- **Consistent clinical notes** over time, including family doctor, specialty and hospital records.
- **Treatment history.** Insurers often argue that a claimant did not follow recommended treatment. Records of appointments, medications, side effects and reasons for any gap answer that point.
- **Your job description** and evidence of the real physical and mental demands of your work, for the own-occupation period.
- **Functional or vocational assessments** where the any-occupation test is in issue.
- **Evidence from people who see you daily**, such as a spouse or former co-worker, describing changes in what you can do.

Conditions without clear test results, such as chronic pain, fibromyalgia, depression or anxiety, are frequent targets for denials based on a "lack of objective evidence". In these files, detailed and consistent descriptions of symptoms and limitations from treating providers are especially important.

## Common mistakes after a denial

- Waiting for the outcome of a second or third internal appeal before speaking to a lawyer.
- Sending the insurer a large stack of records without a covering report that explains how they meet the policy definition.
- Assuming the employer's benefits booklet is the policy.
- Missing the 90-day CPP-D reconsideration deadline, or spending a retroactive CPP payment the insurer will claim back.
- Posting about activities online without thinking about how an insurer could read them.
- Signing a settlement, release or lump-sum buyout without advice on future benefits and tax.
- Resigning from your job without understanding how it affects your coverage and any employment law claims.

## What to bring to your lawyer

To get the most from a first meeting, bring or send:

- Every letter from the insurer, especially the denial or termination letter and any appeal decisions, with the dates you received them.
- The group policy (or your request for it), the benefits booklet and your enrolment forms.
- Your claim forms, attending physician statements and any reports from the insurer's examinations.
- A list of your doctors and treatment providers, with dates.
- CPP disability decisions and correspondence, if any.
- Your job description, recent pay stubs and your T4s.
- A short timeline in your own words: when symptoms began, when you stopped work, and what has happened since.

If your LTD benefits have been denied or cut off, do not let an internal appeal run down the clock. We can review your letters and policy, identify the limitation date, and explain whether an appeal, a lawsuit or both make sense in your situation. Learn more about our [long-term disability](/personal-injury/long-term-disability/) work, and contact us for a free first video meeting.

 

## Common questions

 

How long do I have to sue for denied long-term disability benefits in Ontario?

Generally two years from the day the claim was discovered (Limitations Act, 2002, s. 4). Courts have found that this can run from when the denial became clear and final, but because that is a question of fact, it is safest to count from the first denial letter.

Should I appeal my LTD denial to the insurer or sue?

An internal appeal can fix a simple gap in your paperwork, but the insurer decides its own appeal and the limitation period may keep running. A lawsuit puts the decision before a judge. Get advice on the deadline before choosing.

What is the difference between own occupation and any occupation?

Own occupation asks whether you can do the essential duties of your own job. Any occupation, which many policies apply after the first 24 months, asks whether you can do any job you are reasonably suited for by education, training or experience. The exact wording is in your policy.

Does my LTD insurer reduce my benefits if I get CPP disability?

Usually yes, if your policy has an offset clause, and many policies require you to apply for CPP disability. If CPP pays you retroactively, the insurer may ask you to repay the overlapping amount.

Can my LTD insurer use surveillance against me?

Yes, insurers often use video surveillance and social media. In a lawsuit, surveillance the insurer keeps privileged and does not produce at least 90 days before trial can be used at trial only to impeach a witness or with the judge's leave (Rules of Civil Procedure, r. 30.09).

Can I sue the insurer if my employer holds the group policy?

Yes. A person insured under a group contract can enforce their rights against the insurer in their own name (Insurance Act, s. 318).

 

## Sources

 

1. [Limitations Act, 2002, ss. 4, 5, 7, 15 and 22](https://www.ontario.ca/laws/statute/02l24)
2. [Insurance Act, ss. 293 and 318](https://www.ontario.ca/laws/statute/90i08)
3. [Kassburg v. Sun Life Assurance Company of Canada, 2014 ONCA 922](https://www.ontariocourts.ca/decisions/2014/2014ONCA0922.htm)
4. [Fidler v. Sun Life Assurance Co. of Canada, 2006 SCC 30](https://www.canlii.org/en/ca/scc/doc/2006/2006scc30/2006scc30.html)
5. [Canada Pension Plan, ss. 42 and 81](https://laws-lois.justice.gc.ca/eng/acts/C-8/FullText.html)
6. [Department of Employment and Social Development Act, ss. 52 and 58.1](https://laws-lois.justice.gc.ca/eng/acts/H-5.7/FullText.html)
7. [Courts of Justice Act, s. 105](https://www.ontario.ca/laws/statute/90c43)
8. [Rules of Civil Procedure, rr. 30.09 and 33](https://www.ontario.ca/laws/regulation/900194)

 

General information, not legal advice. Every situation is different, and the law can change. Reading this article doesn't create a lawyer-client relationship.

 

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