Filing an Appeal

In certain cases, Desjardins’ claims administrators may turn down claims for Long Term Disability (LTD) benefits.

If you receive a letter denying your LTD claim, you have the option to appeal and there are no forms to complete. There are two steps in the process.

Step 1: Send more information

To file an appeal, first ensure all essential information detailing your medical condition and how it affects your ability to work is submitted. No form is necessary. Examples of information you can send includes new test results or reports, a summary of your daily symptoms and their impact on your activities, or additional information from your doctor regarding changes in your medical condition or treatment plan.

You should send this information to Desjardins Insurance through the following options:

Online : www.DesjardinsLifeInsurance.com/Send

Fax: 1-855-678-8124

Mail: Box 1024 STN A

Toronto ON M5W 1G5

You are encouraged to send your information within 60 days of your LTD denial or as soon as possible. Remember, you will be responsible for any fees your doctor or treatment provider may charge for this information. However, if you need assistance, Desjardins Insurance can help. There is no limit to the number of times you can appeal. Each time you submit new information your appeal will be reviewed again and a letter will be sent notifying you of the decision.

Your appeal should be reviewed within 30 days by an appeal specialist at Desjardins Insurance, and you will receive a decision by telephone and in writing. Desjardins Insurance might also ask for more information, and/or you may be required to attend an independent medical evaluation.

If you wish to appeal and have confirmed there is no additional essential information to submit, then you can proceed to Step 2.

Step 2: Request a Medical Appeal

Having no additional essential information to submit for your appeal and a denial letter from Desjardins Insurance, you can request a Medical Appeal in writing to Desjardins Insurance within 60 days from the date of your most recent LTD denial.

You may not request a Medical Appeal if you have any additional essential medical information, even for upcoming appointments or tests. Instead, this additional information must first be sent to Desjardins Insurance for review.

Further, you may request a Medical Appeal only if Desjardins Insurance denied your LTD benefits because they determined you did not meet the definition of disability. A Medical Appeal cannot be requested if your LTD benefits were denied for other reasons, such as pre-existing medical conditions or if you did not have LTD benefit coverage.

In a Medical Appeal, three physicians will review your file. This panel includes one physician you chose, typically, your family doctor and two independent physicians. Desjardins Insurance will select an independent physician who is acceptable to your doctor, while your doctor will choose a physician who is acceptable to Desjardins Insurance. Both independent physicians must have the necessary expertise in the relevant area of the appeal.

The Medical Appeal panel may request further examination, testing and/or additional information. However, you will not be required to appear before the panel. They will provide a written opinion on whether your medical condition meets the Core LTD Program Text definition of disability. For the decision to be binding, at least two physicians must agree. The panel’s decision is final and cannot be further reviewed. There is no cost to you for a Medical Appeal unless two or three physicians determine that you do not meet the definition of disability. In this case, you will be responsible only for your doctor’s charges.

For more information about LTD appeal process, refer to the complete plan provisions in the Core Long Term Disability Program (PDF) document.