Can LTD Insurance Be Denied Because of Your Medical History?

When an injury or illness prevents you from working, long-term disability insurance may replace part of your lost income. Many people fear that an old injury, past illness, or mental health issue will lead to a denied claim.

Your medical history can affect an LTD claim, but a past condition does not automatically prevent you from receiving benefits.

In Canada, an insurer’s decision must be based on the wording of the insurance policy and the available evidence. An insurer cannot deny a claim simply because you had health problems before becoming disabled.

What matters is whether your medical history triggers a specific policy term. This could include a pre-existing condition exclusion, a major mistake on your insurance application, or proof that you don’t meet the policy’s definition of disability.

Understanding how insurers review medical history can help you prepare a stronger claim and respond to an unfair denial.

Understanding LTD Insurance

Long-term disability insurance is meant to replace part of your income when a medical condition prevents you from working for an extended period.

There are two main types of LTD coverage:

  • Group LTD insurance, which is often provided through an employer, union, or professional association.
  • Private LTD insurance, which is purchased directly from an insurance company or advisor.

In both cases, LTD coverage is based on a legal contract. The policy explains who is covered, how disability is defined, when benefits begin, how much the insurer must pay, and when coverage may be limited or denied.

The exact policy wording matters.

Two people with similar medical conditions may receive different decisions because their policies contain different definitions, exclusions, waiting periods, or coverage dates.

Do not rely only on an employee benefits booklet. The full policy may contain important terms that do not appear in a short summary.

How Insurers Assess LTD Claims

The LTD claim process usually begins with forms completed by you, your employer, and your healthcare provider.

You may need to provide information about your diagnosis, symptoms, treatment, medications, job duties, restrictions, and limitations. Your doctor may also need to provide clinical notes, test results, specialist reports, treatment plans, and information about your expected recovery.

The insurer will compare your medical condition and functional limits with the demands of your job and the terms of the policy.

Your claim should explain more than the name of your diagnosis. It should show how your condition prevents you from completing the important duties of your job.

Depending on your condition and job, this may involve:

  • Difficulty sitting
  • Standing
  • Walking
  • Lifting
  • Concentrating
  • Remembering instructions
  • Managing stress
  • Maintaining attendance
  • Interacting with others, and/or
  • Working at a steady pace

A complete claim may reduce delays and make it harder for the insurer to argue that there is not enough evidence.

Insurers may also use vocational assessments, independent medical examinations, functional capacity evaluations, and policy reviews.

A vocational assessment looks at your education, training, work history, skills, and abilities. It may be used to decide whether you can return to your previous job or perform another type of work.

An independent medical examination, or IME, is an assessment completed by a healthcare provider chosen by the insurer. The insurer may use it to get another opinion about your diagnosis, treatment, restrictions, recovery, or ability to work.

A functional capacity evaluation, or FCE, tests your ability to perform work-related tasks. It may assess lifting, carrying, bending, sitting, standing, walking, reaching, and maintaining effort over time.

The insurer will also review the policy to decide whether you meet the definition of disability and whether any exclusions or limitations apply.

Medical History and LTD Coverage

Your medical history can play an important role in an LTD claim. A past illness, injury, or mental health issue doesn’t mean you can’t get benefits.

The insurer will usually consider your current condition, your ability to work, the date your coverage began, and whether you had related medical problems before that date.

Medical history can include:

  • Diagnosed conditions
  • Symptoms without a diagnosis
  • Doctor visits
  • Hospital records
  • Specialist referrals
  • Counseling
  • Prescription medications
  • Physiotherapy
  • Medical tests
  • Previous disability leaves, and/or
  • Workplace accommodations.

An insurer’s review is not limited to serious illnesses. A brief complaint in a family doctor’s notes may be examined if the insurer believes it is like the condition supporting your current claim.

The insurer may check past complaints like back pain, headaches, fatigue, anxiety, numbness, dizziness, or poor sleep.

However, an earlier symptom does not prove that your current disability is pre-existing.

The earlier problem may have been temporary or fully resolved. Your current disability may have a different cause, affect a different part of your body, or be much more serious.

Medical records should be considered as a whole. One isolated note should not be treated as final proof that your disabling condition existed before your coverage began.

What Medical Information May Be Required From the Past Five Years?

An LTD insurer may ask for details about your healthcare providers. This includes doctors, clinics, hospitals, and therapists you visited in the last five years.

Five years is not a fixed rule. Some insurers ask for a shorter period, while others may request records going back five years or longer.

The requested period can depend on several things. These include the policy wording, the claim forms, and the medical condition. It also depends on whether the insurer is checking for a possible pre-existing condition or non-disclosure.

You might need to share names and contact details for:

  • Your family doctor
  • Walk-in clinics
  • Specialists
  • Psychologists
  • Counsellors
  • Physiotherapists
  • Chiropractors
  • Occupational therapists, and/or
  • Other treatment providers.

The insurer may also ask you to sign an authorization allowing it to get relevant records directly from those providers.

The information you asked for may include:

  • Family doctor charts;
  • Walk-in clinic notes;
  • Emergency room reports;
  • Hospital records;
  • Specialist reports;
  • Counselling notes;
  • Physiotherapy records;
  • Test results;
  • Prescription histories;
  • Surgical records; and
  • Details about past times you couldn’t work.

You may also need to personally provide information about:

  • Previous medical appointments and treatment;
  • Prescription medications and dosage changes;
  • X-rays, MRIs, CT scans, bloodwork, and other testing;
  • Previous disability claims or medical leaves;
  • Reduced hours, modified duties, or workplace accommodations;
  • Mental health treatment; and
  • Earlier injuries or symptoms that appear like your current condition.

Try to provide complete and accurate information. Do not leave out a provider simply because you think the treatment is unrelated.

If you do not remember an exact date, explain that the date is approximate rather than guessing.

Five Years of Records Is Not the Same as the Look-Back Period

A request for five years of medical records is different from a pre-existing condition look-back period.

The look-back period is the time before your LTD coverage started. During this time, treatment or symptoms can lead to a pre-existing condition exclusion.

For example, a policy may look at treatment received during the three or six months before coverage began. However, the insurer may still request five years of records to understand the broader history of your condition.

This does not mean that every condition mentioned during those five years can be excluded.

The insurer must still apply the exact wording of the policy. It must check if treatment happened during the look-back period. It also needs to see if the earlier condition relates to the current disability.

Read the Medical Authorization Carefully

Before signing a medical authorization, read it carefully.

Verify what information the insurer can collect. Check which organizations may get this info, the time frame it covers, and how long it stays valid.

Refusing to provide information that is reasonably needed to assess the claim may prevent the insurer from making a decision.

However, this does not always mean the insurer is entitled to every medical record you have ever created.

A broad request might need more review if it asks for personal information. This is especially true if the information appears unrelated to your disability, the policy, or the insurer’s concerns.

Review Your Own Medical Records

When possible, get and review your own medical records before submitting your claim.

Medical charts can have errors. They might include incomplete details, copied text, or brief notes that miss important information.

You cannot simply remove an unfavorable entry. However, you may ask the healthcare provider to correct a clear factual mistake or add clarification.

Reviewing your records may also help you identify earlier complaints that the insurer may raise.

Your doctor may be able to explain that the earlier symptoms were temporary, had resolved, involved a different condition, or did not affect your ability to work.

For example, a person might have had back stiffness years ago. They worked without problems. Then, they got a serious spinal condition.

A person who attended a few counselling sessions in the past may later develop a separate and much more serious mental health disability.

Evidence that you recovered, returned to work, and successfully performed your duties can be just as important as the earlier medical complaint.

Keep Copies of Everything You Submit

Keep a copy of every document you provide to the insurer.

This includes your employee statement, medical forms, authorizations, records, specialist reports, letters, emails, and appeal materials.

Record when and how each document was submitted.

A complete file is crucial if your claim is denied. It helps you see what the insurer looked at, misunderstood, or missed.

Why Insurers Investigate Medical History

Insurers review past medical information for several reasons.

First, they may be assessing risk. This is more common with private policies or optional coverage that requires medical evidence. If key information is omitted during the application, the insurer might claim it couldn’t properly assess the risk.

Second, the insurer may be checking whether a pre-existing condition clause applies.

Third, it can check past records to see when symptoms started. It will also look at what treatment was given and if the current claim matches the medical history.

Finally, LTD claims can involve monthly payments over many years. Insurers have a financial interest in determining whether an exclusion or other policy defense applies.

This does not mean every investigation is improper. However, an insurer is not your doctor or personal advisor. It is the other party to an insurance contract and has its own financial interests.

What Is a Pre-Existing Condition?

A pre-existing condition is generally an illness, injury, symptom, or medical issue that existed before your LTD coverage became effective.

The definition may be broader than a diagnosed illness.

A policy may define a pre-existing condition as a sickness or injury for which you received medical care, consultation, treatment, medication, services, or advice during a set period before coverage began.

Some policies also include symptoms for which a reasonable person would have sought medical care, even if no diagnosis had been made.

The exact wording matters. A denial should be based on the language of the insurance contract, not simply on the fact that you have had previous health problems.

How Pre-Existing Condition Clauses Are Used

An insurer can deny your claim. This can happen if they see your current disability is linked to a condition treated during the policy’s look-back period.

For example, a person may have received treatment for back pain before becoming insured and later made a claim involving a disc injury.

The insurer may argue that the earlier pain and later injury are connected.

However, similarity alone may not be enough.

The earlier pain may have been temporary, muscular, or fully resolved. The later disability may involve a new diagnosis. It can have different symptoms. It may also lead to more serious functional limitations.

The insurer should consider all medical evidence rather than relying solely on the same body parts or a single symptom.

Look-Back and Exclusion Periods

The look-back period is the time before coverage begins that the insurer may examine for pre-existing conditions.

It is often measured in months. The exact period varies between policies.

The relevant date is usually the date your coverage became effective, not the date you submitted the claim.

Many policies also contain an exclusion period. This limits how long a pre-existing condition exclusion can affect a claim.

For example, the exclusion may only apply if your disability begins during the first 12 or 24 months after coverage starts.

If you remain able to work beyond that period and become disabled later, the exclusion may no longer apply.

The dates of coverage, treatment, disability, and your last day of work can therefore be very important.

What Counts as Medical Care?

Policies may define medical care as including examinations, prescriptions, referrals, therapy, diagnostic testing, or medical advice.

However, disputes often arise over what counts as meaningful care.

Questions may include:

  • Was the routine checkup adequate?
  • Was a symptom only mentioned briefly?
  • Was medication prescribed for a different purpose?
  • Were the earlier symptoms mild and did they resolve?

The answer depends on the policy and the medical evidence.

The insurer should look at the care given, the condition involved, and whether it is linked to the disability stopping you from working.

Symptoms Without a Diagnosis

An insurer may raise a pre-existing condition issue even if you have not received a formal diagnosis.

Some policies list symptoms that should have made a reasonable person seek care.

A short complaint without investigation, treatment, or follow-up might not show a clear link to a later disability.

The insurer should think about several key points. First, how serious were the earlier symptoms? Next, how long did they last? Was treatment given? Was the issue resolved? Finally, does medical evidence link them to the current condition?

Material Misrepresentation and Non-Disclosure

Medical history may also become an issue if you complete a health questionnaire when applying for coverage.

The insurer may argue that you gave an incorrect answer or failed to disclose an important condition.

However, not every mistake or omission allows the insurer to cancel coverage or deny a claim.

The missing information generally must be material. This means it must have been important enough to affect the insurer’s decision to provide coverage, charge a certain premium, or add an exclusion.

Not sharing a serious condition that was recently checked could be treated differently. It’s not the same as forgetting a minor complaint from years ago that is already resolved.

The wording of the application questions also matters. Broad or confusing questions may create a valid dispute over what the applicant is expected to disclose.

You Must Still Prove Your Current Disability

Even if no pre-existing condition exclusion applies, you must still prove that you meet the policy’s definition of disability.

During the first stage of many LTD policies, the issue is whether your condition prevents you from performing the main duties of your own occupation.

After a set period, often two years, the definition may change. You may need to prove that you cannot do another job that fits your education, training, or experience.

The insurer may consider your diagnosis, symptoms, test results, treatment, restrictions, limitations, job duties, attendance, medication side effects, recovery, and return-to-work attempts.

A diagnosis alone may not be enough.

Your healthcare providers should clearly explain what you cannot do and why. They should also detail how these limits affect your ability to meet the demands of your work. Understanding this helps you grasp the reasons behind your restrictions.

Independent Medical Examinations

Disputes may arise when your treating doctor and an insurer’s medical examiner reach different conclusions.

Your doctor may believe you are unable to work, while the insurer may rely on an Independent Medical Examination (“IME”) or paper review suggesting that you can return.

An IME may involve only one appointment. The examiner may not know your medical history as well as your family doctor or specialist.

When doctors disagree, key factors to consider are:

  • How long each doctor treated or assessed you;
  • If the complete medical file was reviewed;
  • Whether the assessment was thorough; and
  • If the opinion considers your actual job duties.

A difference of opinion does not automatically justify a denial. The insurer’s decision should be supported by clear reasons and evidence.

Can LTD Be Denied Solely Because of Medical History?

In most cases, medical history alone should not be enough to deny an LTD claim.

Previous back pain, migraines, depression, anxiety, or other health concerns are common. LTD coverage would offer little protection if any earlier health problems automatically prevent a person from receiving benefits.

The real question is whether your medical history triggers a specific policy term.

A denial can happen for a few reasons:

  • There may be a valid pre-existing condition exclusion;
  • There could be a material misrepresentation on the application; or
  • The definition of disability might not be met.

However, the insurer must connect the denial to the wording of the policy and the evidence.

A brief symptom noted in passing may not trigger an exclusion. A resolved condition may not be connected to a later disability. Vague symptoms with no treatment or investigation may not meet the policy requirements.

The insurer should identify the relevant policy language, the treatment or symptoms during the look-back period, and the medical connection between the earlier condition and the current disability.

A general statement that the condition “existed before” may not be enough.

What Should You Do If Your Claim Is Denied?

A denial does not necessarily mean your claim is invalid.

You can challenge medical history-based denials if the insurer:

  • Relied on incomplete records;
  • Misunderstood an earlier condition;
  • Used the wrong dates; or
  • Interpreted the policy too broadly.

Start by reading the denial letter carefully.

Identify whether the insurer is relying on a pre-existing condition clause, alleged non-disclosure, insufficient medical evidence, or a finding that you do not meet the definition of disability.

Request the complete LTD policy, not just the employee benefits booklet. Review the definition of disability, coverage date, look-back period, exclusion period, appeal rules, and deadlines.

Ask for the information used to make the decision. This may include medical reviews, correspondence, IME reports, vocational assessments, and other material relied on by the insurer.

Check the timeline. Confirm the date your coverage began, the dates of earlier treatment, when your current symptoms started, when you stopped working, and when your disability began.

Ask your doctor to provide clarification. Your doctor may be able to explain that an earlier complaint was unrelated, temporary, resolved, or did not affect your ability to work.

Many policies allow an internal appeal. You can use an appeal to send updated medical records. It also lets you add specialist reports, treatment notes, and functional evidence. Plus, you can write a response to the insurer’s concerns.

Prepare an appeal carefully because anything submitted may become part of the permanent claims record.

You should also pay close attention to deadlines. An internal appeal deadline may be different from the legal deadline for starting a court action. Repeated appeals may not extend the legal limitation period.

Speak With an LTD Lawyer

A denial based on medical history can be stressful, especially when you are already unable to work.

An LTD lawyer can review the policy, medical records, application forms, denial letter, and important dates. A lawyer can check if the insurer has linked an old condition to your current disability.

At NOVA Injury Law, our disability lawyers help people understand their LTD coverage, respond to denials, and pursue the benefits they may be entitled to receive.

If your long-term disability claim has been denied because of your medical history, contact NOVA Injury Law for a free consultation at info@novainjurylaw.com.