Living with an autoimmune disease can be unpredictable, debilitating, and life-altering. For many individuals in Alberta, these conditions interfere with their ability to maintain consistent employment, leading them to seek long-term disability (“LTD”) benefits. However, obtaining and maintaining LTD benefits for autoimmune conditions can be particularly challenging. These claims often involve complex medical evidence, fluctuating symptoms, and scrutiny from insurers.
Understanding Autoimmune Diseases in the LTD Context
Autoimmune diseases occur when the body’s immune system mistakenly attacks its own tissues. There are over 80 recognized autoimmune conditions, including rheumatoid arthritis, lupus, multiple sclerosis, Crohn’s disease, and psoriasis. Many of these conditions are chronic, progressive, and characterized by periods of remission and flare-ups.
From an LTD perspective, the key issue is not simply the diagnosis, but how the condition impacts a person’s functional ability to work. Insurers will assess whether your symptoms prevent you from performing the essential duties of your occupation—or any occupation, depending on the stage of your claim.
Autoimmune diseases often present unique challenges because symptoms can vary significantly over time. A claimant may appear capable on some days but be severely limited on others. This inconsistency can complicate the evidentiary record and lead insurers to question the severity or persistence of the disability.
How LTD Policies Define Disability
Most LTD policies in Canada apply a two-stage definition of disability. During the initial period—often the first 24 months—a claimant must demonstrate that they are unable to perform the substantial duties of their “own occupation.” After that period, the definition typically shifts to an “any occupation” standard, meaning the claimant must be unable to perform any gainful employment for which they are reasonably suited by education, training, or experience.
For individuals with autoimmune diseases, this transition can be particularly difficult. While symptoms may clearly prevent a person from continuing in a physically demanding or high-stress role, insurers may argue that the claimant is capable of performing lighter or sedentary work.
As a result, medical documentation must clearly explain not only the diagnosis, but also the functional limitations associated with the condition, including fatigue, pain, cognitive impairment (“brain fog”), and the need for unpredictable absences.
The Role of Medical Evidence
Medical evidence is central to any LTD claim, but it is especially critical in cases involving autoimmune diseases. Because many symptoms are subjective and not always visible on imaging or laboratory tests, insurers often rely heavily on clinical notes and physician reports.
Treating physicians—such as rheumatologists, neurologists, or gastroenterologists—play a key role in documenting the nature and severity of the condition. Detailed records should address how symptoms impact the claimant’s ability to sit, stand, concentrate, interact with others, and maintain a regular work schedule.
Consistency in medical reporting is essential. Gaps in treatment, vague descriptions, or conflicting opinions can undermine a claim. Insurers may also request Independent Medical Examinations (“IMEs”) to obtain their own assessment of the claimant’s condition. These examinations are not always neutral and should be approached with care.
Common Challenges in Autoimmune LTD Claims
Individuals with autoimmune diseases often encounter specific hurdles when applying for or maintaining LTD benefits. One of the most common issues is the fluctuating nature of symptoms. Insurers may rely on isolated observations, such as surveillance footage or a single medical appointment, to argue that the claimant is capable of working.
Another challenge is the lack of “objective” medical evidence. While some autoimmune conditions produce measurable markers, others do not. Insurers may use this absence of objective findings to question the legitimacy of the claim, even when the claimant’s symptoms are well-documented and supported by treating physicians.
Fatigue and cognitive impairment are also frequently underestimated. These symptoms can be just as disabling as physical limitations, particularly in roles that require sustained attention, decision-making, or interpersonal interaction.
Finally, claimants may face pressure to participate in rehabilitation or return-to-work programs. While these initiatives can be beneficial in some cases, they must be appropriate given the individual’s medical condition. Premature or unsuitable return-to-work efforts can worsen symptoms and jeopardize long-term recovery.
Surveillance and Credibility Concerns
Insurance companies may conduct surveillance to assess the legitimacy of an LTD claim. This can include video monitoring, social media review, and other investigative techniques. For individuals with autoimmune diseases, this can be particularly problematic, as brief periods of activity may not reflect overall functional capacity.
For example, a claimant may be able to attend a social event or run a short errand on a “good day,” but still be unable to sustain regular employment. Insurers may nevertheless use such evidence to argue that the claimant is not disabled.
Credibility becomes a central issue in these cases. Consistency between reported symptoms, medical records, and observed activities is critical. Claimants should be mindful of how their condition is documented and how their activities may be interpreted.
The Importance of Functional Evidence
In addition to medical diagnoses, insurers focus heavily on functional capacity. This includes the ability to perform tasks such as sitting for extended periods, maintaining concentration, meeting deadlines, and attending work reliably.
Functional Capacity Evaluations (“FCEs”) may be used to assess these abilities. However, like IMEs, these assessments may not fully capture the episodic nature of autoimmune diseases. A single evaluation may not reflect the cumulative impact of fatigue or the variability of symptoms over time.
Detailed self-reporting, supported by medical evidence, can help bridge this gap. Keeping a record of symptoms, flare-ups, and their impact on daily activities can provide valuable context for insurers and, if necessary, the court.
Denials and Terminations of LTD Benefits
It is not uncommon for LTD claims involving autoimmune diseases to be denied at the initial application stage or terminated after a period of payment. Insurers may argue that the claimant does not meet the policy definition of disability, that there is insufficient medical evidence, or that the claimant is capable of alternative employment.
A denial or termination is not the end of the process. Claimants may have the option to appeal the decision internally or pursue legal action. It is important to be aware of applicable limitation periods, which can restrict the time available to challenge a denial.
In many cases, early legal advice can be beneficial. A lawyer can assist in gathering appropriate evidence, addressing deficiencies in the claim, and advocating on behalf of the claimant.
The Intersection of LTD and Personal Injury Claims
For individuals whose autoimmune condition is triggered or exacerbated by an accident (such as a motor vehicle collision), there may be an overlap between LTD benefits and personal injury claims. In these cases, multiple insurers may be involved, and coordination between claims becomes important.
LTD insurers may seek reimbursement from personal injury settlements or reduce benefits based on other sources of income. Understanding how these systems interact is essential to ensuring that claimants receive the full benefits to which they are entitled.
Contact Cuming & Gillespie LLP in Calgary to Get Help With Your LTD Claim
If your long-term disability claim has been denied, delayed, or terminated due to an autoimmune disease, you do not have to face the process alone. At Cuming & Gillespie LLP, our personal injury lawyers have extensive experience handling LTD disputes, including complex claims involving chronic illness, invisible disabilities, and fluctuating medical conditions.
We assist clients with LTD applications, appeals, and litigation against insurance companies. Whether you are dealing with rheumatoid arthritis, lupus, multiple sclerosis, or another autoimmune condition, we can help you build a strong, evidence-based claim and pursue the benefits you deserve.
Contact Cuming & Gillespie LLP online or call (403) 571-0555 for a confidential consultation. We will review your policy, assess your claim, and provide clear, strategic advice tailored to your situation.