Long-term disability (LTD) benefits in Ontario are designed to provide financial support to individuals who are unable to work due to an injury or a medical condition. These benefits are typically offered through private insurance plans, often provided by employers.
To qualify for LTD benefits, an individual must meet specific medical and occupational criteria, which vary depending on the insurance policy.
Medical Conditions That Qualify
There is no exhaustive list of conditions that automatically qualify for LTD benefits in Ontario, as eligibility is primarily based on how a condition affects an individual’s ability to work.
Common qualifying conditions include the following:
- Musculoskeletal Disorders – Chronic pain conditions, severe arthritis, degenerative disc disease, sciatica, and spinal injuries that limit mobility and prevent physical work.
- Mental Health Conditions – Severe depression, anxiety disorders, bipolar disorder, post-traumatic stress disorder (PTSD), schizophrenia, developmental disorders, personality disorders, attention-deficit/hyperactivity disorders, eating disorders, and addictions, particularly when these conditions prevent an individual from performing work duties consistently.
- Neurological Disorders – traumatic brain injury, brain tumors, cerebral palsy, stroke, multiple sclerosis, Parkinson’s disease, epilepsy, muscular dystrophy, and other disorders affecting the nervous system that impair cognitive or motor function.
- Cardiovascular Conditions – Severe heart disease, stroke recovery, and other heart-related conditions that limit an individual’s stamina and ability to perform job tasks.
- Chronic Illnesses – Conditions such as cancer, lupus, fibromyalgia, diabetes, gout, and chronic fatigue syndrome that result in prolonged periods of impairment and prevent consistent work.
Each LTD claim is assessed on a case-by-case basis, with medical documentation playing a crucial role in determining both initial eligibility as well as ongoing entitlement.
Occupational Test for LTD Eligibility
Typically, an individual with coverage for LTD would have coverage first for short-term disability benefits (STD). LTD benefits start once the STD benefits coverage period is exhausted.
Most LTD policies follow a two-stage test to assess eligibility:
- Own Occupation Test (First Two Years): During the first 24 months of LTD benefits, an individual must demonstrate that they are unable to perform the essential duties of their own job due to their condition.
- Any Occupation Test (After Two Years): After two years, the criteria become stricter. The individual must prove that their condition prevents them from performing any occupation for which they are reasonably suited based on their education, training, or experience.
If an applicant is unable to meet the “any occupation” test, they may not continue receiving LTD benefits beyond the two-year mark.
Additional Considerations
- Medical Evidence: Applicants must provide comprehensive medical records, physician statements, and sometimes independent medical evaluations to support their claim.
- Insurance Policy Terms: Different policies may have varying definitions of disability, exclusions, and pre-existing condition clauses that could impact eligibility.
- Government LTD Benefits: If private LTD benefits are denied, individuals may still qualify for CPP Disability Benefits, which require proof of a severe and prolonged disability.
Conclusion
To qualify for long-term disability benefits in Ontario, an individual must demonstrate that their medical condition significantly impairs their ability to work. While there is no fixed list of qualifying conditions, both physical and mental health disorders can be eligible if they meet the criteria outlined in the insurance policy. A thorough medical assessment and strong supporting evidence are key factors in a successful LTD claim.
Contact our experienced lawyers at Matthews Abogado Disability Lawyers for a free consultation. We can assist you with navigating the intricacies of proving initial entitlement and well as ongoing entitlement.
