Ask The Lawyer

The Turning Point in Disability Claims: What Changes and Why (April 2026)

Weir Bowen LLP Season 5 Episode 4

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This month on Ask the Lawyer, Cynthia Carels and Ian Miller break down the realities of disability claims in Canada. From how disability insurance works to why claims are often denied, they walk through the key issues people face when they are unable to work. 

The conversation also explores mental health claims and "invisible disabilities" like chronic pain and fibromyalgia, and why these cases can be especially difficult to prove. A practical discussion to help you better understand your coverage, your rights, and what steps to take if your claim is challenged. 

Ask the Lawyer is heard the last Saturday of the Month on CFWE North & CJWE South in Alberta, Canada. For more information visit www.weirbowen.com & cfweradio.ca. 


Welcome And Guest Introductions

Warren Berg

Good morning and welcome to the April edition of Ask the Lawyer across Alberta on Windspeaker Radio, C FWE and CJWE. I'm your host, Warren Berg, and joining us this month, two familiar faces, Cynthia Carrolls and Ian Miller of Weirbone LLP in Edmonton. Great to have you both back.

Cynthia Carels

It's always a pleasure, Warren. And we know we really do look forward to doing this every month with you.

SPEAKER_00

Agreed. Thanks for the platform. We're uh very happy to be here.

Warren Berg

We're Bowen LLP is an Edmonton-based law firm. However, their lawyers have represented clients across Alberta, BC, Saskatchewan, and the Northwest Territories, and have been counsel in precedent sending cases all the way up to the Supreme Court of Canada.

Cynthia Carels

Yeah, absolutely. And you know, at Wearbowen, we really do pride ourselves on the firm's range as well as uh the track record.

Awards And What They Signal

SPEAKER_00

And uh that track record is built on the foundation laid by Weirbowen's founding partners. Every lawyer who has joined the firm over the years has been shaped by that legacy. And I think uh you can feel it in the way that we approach our files and uh serve our clients.

Warren Berg

And speaking of reputation, Weirbowen has been receiving some notable recognition lately. Let's talk a little bit about that. Ian, I understand a number of your lawyers have been honored in a big way this year.

SPEAKER_00

Yes, and uh we're very proud of this. So five of our lawyers, including Cynthia here, have been recognized in the 2026 Canadian Legal Expert Directory as some of Canada's leading legal practitioners in the field of personal injury and medical negligence litigation. So that kind of recognition coming from the broader legal profession itself, including our competitors and even opposing counsel, uh it really does mean a lot.

Warren Berg

So congratulations to Cynthia and of course all of your colleagues. Now, Cynthia, can you maybe walk our listeners through who's being recognized and what they're being honored for?

Cynthia Carels

Yeah, you know, thanks, Warren. And I'd certainly love to uh celebrate my colleagues. So I'll start with our our own Sheila McGregor, who many listeners will know from previous episodes of Ask the Lawyer. Uh Sheila has actually been recognized both in personal injury as well as medical negligence. And I want to emphasize that her recognition is specifically for the work that she does on the victims side of these really challenging files. These are some of the most challenging cases in the legal system, and Sheila is truly exceptional at them.

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Yep.

SPEAKER_00

And then there's Joel Miller, one of our longest-serving lawyers, having joined Weir Bowen all the way back in 1991. So Joe is recognized for medical malpractice and personal injury litigation, and his depth of experience is really hard to overstate.

Cynthia Carels

That's a fair comment, honestly. Joe is a a titan in the area.

SPEAKER_00

Absolutely. So he's prosecuted some of the largest personal injury claims in Alberta's history, including highly complex birth injury trials that have genuinely shaped the law in this province.

Cynthia Carels

And we're also proud to have Dave DeVere, our office managing partner, recognized again this year for his work also in medical malpractice litigation. Uh and joining the group in 2026 is also our partner Mike McVeigh, who was also honored in medical malpractice, which really reflects the depth that um we have at Weir Bowen in that area specifically. And of course, like Ian mentioned, I'm humbled to be included in that group as well.

Warren Berg

So five Weir Bowen lawyers recognized as leading legal practitioners in the 2026 Lexpert Dictionary or Directory, pardon me. That really speaks to the breadth of the talent at the firm. What does that kind of recognition actually mean for somebody who's looking for legal help? One, why should that matter to them?

SPEAKER_00

It matters because it's real. So the Lexpert Directory is based on peer reviews, which is lawyers and firm leaders evaluating one another's work. It's not a paid listing. It's not a popularity contest, and it's not an advertisement dressed up as an award. In an era where AI-generated reviews, bot farms, and pay-to-play honors are genuinely difficult to distinguish from the real thing. Peer-reviewed recognition like this gives the public a trustworthy signal about where quality legal work is actually being done.

Cynthia Carels

And that matters especially when someone is going through something as stressful as, you know, a disability claim, a medical malpractice case, or some serious bodily injury. People really do deserve to know that the lawyers they're trusting have been independently vetted and validated by people who actually know this work best, which is truly other lawyers.

Warren Berg

And that's a really important point. I mean, is there any other firm-level recognition our listeners should know about?

SPEAKER_00

Yes. So Weirbowen has actually been recognized locally and nationally with Tier 1 rankings by the best law firms in Canada. So nationally, we hold a tier one ranking in personal injury litigation. And here in Edmonton, we've um received Tier 1 rankings in insurance law, medical negligence, and personal injury litigation. So, like the Lexpert recognition, this is again based on genuine peer reviews and uh confirmed client interviews.

Warren Berg

That's a remarkable amount of recognition. And and more importantly, I think it tells our listeners that they're in good hands. So let's get into it. Uh Cynthia, what are we covering today?

Cynthia Carels

So today we're going to be focusing on the area of disability law and specifically what happens when a person becomes too ill or injured to actually be able to do their work, and they're going to need to rely on disability insurance to keep them financially afloat. And this is an area that touches so many people, yet it's one that most people know very little about until they're suddenly right in the middle of it. So we have a bit of an agenda for today's show. We're going to start by breaking down how disability insurance actually works, uh, you know, the basics that everyone should understand before they ever need to make a claim. Then we're going to get into two areas that we see coming up more and more in our practice mental health disability claims and what are sometimes called invisible disabilities, like chronic pain or something like fibromyalgia. And these conditions, um, you know, they can be every bit as debilitating as a physical injury, you know, like a broken leg or, you know, fractured pelvis or something. Uh, but these ones face a very different and often much harder road when it comes to getting insurers to actually pay.

Disability Insurance Basics And Coverage

Warren Berg

Okay, so now before we get into anything too specific, I think it would be a really helpful idea for our listeners to give a bit of a foundation. Ian, can you give us a general overview of what disability insurance actually is and how it's supposed to work, and uh maybe what are the basics that everyone should understand?

SPEAKER_00

Absolutely, and uh it's a great place to start uh because a lot of people have disability coverage and they don't really understand what they have until they need it. So let's break it down. Disability insurance exists to replace a portion of your income when a medical condition, whether physical or psychological, uh restricts your ability to work. So most policies will pay somewhere in the range of 60 to 75 percent of your pre-disability earnings. So it's not a full replacement of your income, uh, but it's designed to keep you financially afloat while you focus on your health and recovery.

Warren Berg

And maybe where does that coverage typically come from? Is it something that people buy on their own or is it provided through work?

SPEAKER_00

Both actually. So some people purchase individual uh disability policies directly through an insurance broker. But the most common source of disability coverage for working Canadians is through their employer, what's called a group benefits plan. So if you work for an organization that offers a benefits package, there's a good chance you have some form of disability coverage included in it, often without having fully read or understood what it covers.

Cynthia Carels

And you know, that's actually one of the biggest issues that we see. People will be paying into these plans sometimes for you know years or decades, and they only have sort of a vague sense of what they're entitled to. Then when something happens and they actually need to make a claim, they're suddenly trying to understand, you know, super complex insurance policy when they're under enormous stress. Uh, and that's obviously not a good position to be in.

Own Occupation Versus Any Occupation

Warren Berg

So, what might be some of the key things that people should understand about their policy before they ever need to use it?

SPEAKER_00

So the the single most important thing is understanding how your policy actually uh defines the word disability. And this is where things uh can get a little bit more technical, but it's really worth understanding because the definition of disability in your policy is essentially the threshold that you have to meet to qualify for benefits, and not all definitions are created equally. So maybe can you walk us through what those definitions might look like? Sure. So most long-term disability policies use one of two main definitions, or a combination of both applied at different stages of your claim. So the first is called the own occupation definition. So under this definition, you are considered disabled if your medical condition prevents you from performing uh the essential duties of your own specific job. So the job you were actually doing when you became disabled. So this is generally the more generous of the two definitions because it's measured against what you specifically do for a living.

Cynthia Carels

So for example, let's say you were a surgeon and you develop a condition that prevents you from operating. Even though you could theoretically do other kinds of work, you could still be qualified as disabled under that own occupation definition because you can no longer perform the core duties of your own particular occupation.

Warren Berg

Okay, that makes sense.

SPEAKER_00

What about the second definition? So the second is called the any occupation definition, and this is a higher bar to clear. So under this definition, you're only considered disabled if your condition prevents you from performing the duties of any occupation for which you are reasonably suited by your educated education, training, um, and experience. So the question is no longer just can you do your specific job? It becomes can you do any job that's reasonably suited to your education, training, and experience.

Cynthia Carels

And this is where a lot of claims run into trouble because someone might be genuinely unable to return to the work they've done for their whole career, uh, physically or psychologically, but the insurer argues they could theoretically do some other kind of lighter work or different work, uh, and that argument ends up being used to deny or cut off benefits even when the person is far from recovered and far from capable of you know going back to meaningful employment.

Warren Berg

So I guess a person could go from qualifying under one definition but also denied under the other? Exactly.

SPEAKER_00

And this is uh one of the most important things for listeners to understand. Many policies start with the own occupation definition for an initial period, often the first two years of a claim. Uh and after that, the definition may automatically shift to any occupation. So someone might be receiving benefits without any issue for two years, and then suddenly their benefits get cut off, not because their condition has improved, but simply because the goalposts have moved. So the insurer is now applying a completely different and harsher standard to the definition of disability.

Cynthia Carels

And we see this transition point causing enormous hardship. Uh the person themselves hasn't changed. Uh, their medical system may not have changed significantly either, but the legal test they have to meet has changed, and the insurer takes full advantage of that, and it can catch people off guard.

Warren Berg

So, what should somebody do to protect themselves at this transition point?

SPEAKER_00

Well, uh, to the extent it is within your control, we recommend not waiting until the transition happens to start thinking about it. So if you know your policy switches definitions at the two-year mark or whatever the applicable period is in your specific policy, uh, you want to be working with your medical team well in advance to make sure your documentation clearly addresses the any occupation standard, not just your own job. So your physician's reports need to speak about your functional capacity broadly, not just in relation to your uh previous role.

Cynthia Carels

And again, this is where having a lawyer involved really early can pay off because understanding what standards you're going to be held to and making sure that the evidence supports your claim under that standard can really make the difference between keeping your benefits and losing them at what could be a critical time in your recovery.

Planning For The Two Year Switch

Warren Berg

So are there any other key terms or maybe features of a disabil disability policy that our listeners might want to be aware of?

SPEAKER_00

Yeah, there there are a few that are worth flagging. Um most policies have a waiting period, sometimes called uh an elimination period, before benefits kick in. So this is typically somewhere between 90 days and 120 days after the onset of your disability. Uh so during that window, you may be relying on sick leave, short-term disability coverage, EI medical, or your own savings. So it's uh it's worth knowing what the gap looks like in your specific situation before uh you ever need to deal with it.

Cynthia Carels

And there's also typically a requirement that you be under the regular care of a physician for your disabling condition. And of course, this sounds straightforward, but it can become an issue for people who struggle to access consistent medical care, whether because of cost or geography or wait times. Uh, but it is a contractual condition in most policies, and failing to meet that can be used as a reason to deny or terminate benefits.

SPEAKER_00

And uh one more thing worth mentioning. Most policies have strict timelines for filing a claim. Miss those deadlines, and you may face a denial based purely on timing, regardless of how legitimate your disability is. So if you think you might have a claim, don't delay. Get the process started, and even if you're not sure, you'll need it in the wrong if you're not sure you'll need it in the long run.

Warren Berg

So that's a really solid foundation for I think everything that we're going to be talking about today. So with that overview of how disability insurance works generally, let's maybe shift gears a little bit to talk about this subtopic of mental health disability claims. I understand that We're Bowen's disability group is seeing more and more of these kinds of claims. So, Ian, before we get into the legal side of things, can you maybe just set the scene for us? How significant is mental health as a driver of disability claims right now?

Waiting Periods Deadlines Doctor Care

SPEAKER_00

It's uh significant and growing. So mental health conditions, you know, depression, anxiety disorders, PTSD, burnout, are now among the leading causes of long-term disability claims in Canada. Uh so we're not talking about a niche category anymore. This is mainstream. And yet, despite how common these conditions are, the claims that arise from them are among the most frequently denied, the most aggressively disputed, and the hardest for claimants to navigate on their own. There's a real mismatch between how widespread these conditions are and how poorly the insurance system handles them. And why is that? Why are mental health claims treated so differently? So it really comes down to the question of proof. Insurance claims are built around the idea of objective, measurable evidence. They want a test result, an imaging finding, a number they can point to. And with mental health conditions, that kind of evidence just doesn't exist in the same way. You know, you can't do an x-ray for depression, there's no blood panel that confirms an anxiety disorder. And because psychological conditions can't be measured in the same way that a broken bone can, insurers often treat it with a level of skepticism uh that they simply wouldn't apply to a physical condition.

Cynthia Carels

And that skepticism can manifest in really damaging ways. We've seen insurers send claimants to you know their own medical examiners, doctors hired by the insurance company, uh, and those docs will spend an hour or two with the person, then produce a report that uh might contradict years of treatment records from the person's own treating physician. And that report can then become grounds for a denial, and it can feel deeply unfair, and sometimes even harmful. And it seems to happen with mental health claims uh more often than it does with the physical ones.

Warren Berg

So, what conditions are we most commonly talking about when we say mental health disability claims?

SPEAKER_00

So uh depression and anxiety are probably the most common. Major depressive disorder, generalized anxiety disorder, panic disorder. These are conditions that can be absolutely debilitating when they reach a certain severity. Someone in the grips of severe depression may not be able to get out of bed, you know, let alone concentrate on work tasks, manage relationships uh with colleagues, or maintain the kind of reliability and consistency that uh employment requires. You know, anxiety disorders can make it impossible to function in a workplace environment, uh, particularly one that involves stress, interpersonal interaction, or any kind of performance pressure. Uh so beyond those, we're seeing a significant number of claims involving PTSD, uh, particularly among first responders, healthcare workers, and others who've been exposed to traumatic events in the course of their work uh and burnout as well, which has become increasingly recognized as a serious clinical condition, is also uh it's also been showing up more frequently. Uh so these aren't people who are just tired of their jobs. These are people whose nervous systems have been pushed past a breaking point and who need real time and real treatment to recover.

Cynthia Carels

And for Windspeaker uh network listeners specifically, I want to acknowledge that mental health challenges in Indigenous communities can carry additional layers. Uh, you know, intergenerational trauma, the impacts of residential schools, uh, and obviously ongoing effects of systemic inequalities as well. And these are real, documented, medically recognized contributors to mental health conditions, and they absolutely can and do form the basis of legitimate disability claims. Uh so anyone dealing with these kinds of challenges truly deserves the same access to disability coverage as anyone else. And I want to say clearly, if you're you know, First Nations, Metis, Inuit, and dealing with a mental health condition that is affecting your ability to work, your experiences, your history are valid and they matter legally, uh, and they also matter to us.

Warren Berg

Very good point. Let's uh talk about PTSD specifically for a moment, because I think it's a condition that a lot of our listeners may be familiar with, either personally or through somebody that they might know. Ian, how does a PTSD-based disability claim typically look and where does it run into trouble?

Mental Health Claims And Why Denied

SPEAKER_00

So PTSD is one of the most complex and most frequently contested mental health disability claims that we see. It's a condition that develops after exposure to traumatic events, and the symptoms can be profoundly disabling. Flashbacks, nightmares, hypervigilance, emotional numbness, difficulty concentrating, you know, avoidance of anything that triggers memories of the trauma. So these aren't mild inconveniences. Uh for many people, they make ordinary functioning impossible, you know, let alone the demands of a workplace. Uh so where PTSD claims run into trouble is similar to other mental health claims. The insurer questions the severity, questions whether the diagnosis is legitimate, sometimes questions whether the traumatic event itself was as serious as the person says. And because PTSD symptoms can fluctuate, you know, because a person might have periods of relative stability followed by acute crisis, insurers sometimes point to the stable periods as evidence that the person isn't truly disabled. So that is a fundamental misunderstanding of how PTSD works, and it's one that we have to push back on consistently.

Cynthia Carels

And there's also the issue of delayed onset of PTSD as well. So PTSD doesn't always appear immediately after a traumatic event. Sometimes it emerges, you know, weeks, months, even years later, triggered by an accumulation of experiences or by, you know, a secondary event that reopens old wounds. Uh trauma survivors themselves can be amazingly resilient, and sometimes their own body's coping mechanisms won't actually cause them to become activated for extended periods of time for a variety of reasons that we're really only just beginning to understand. So when someone develops PTSD symptoms long after the trauma, insurers sometimes will use that delay to actually question the connection. And again, that's not how the condition works medically. And in many situations, it's not a legitimate basis for a denial, but it's an argument that needs to be addressed with proper expert evidence and often legal support.

Warren Berg

And you I there's still a very real stigma attached to mental health conditions in our society, and I think that's something that a lot of our listeners might recognize, whether they've experienced it themselves or seen it affect somebody they care about. How does that stigma actually impact somebody's disability claim?

SPEAKER_00

Stigma is one of the most insidious problems in the whole area. So we know that people, uh, you know, particularly in certain workplaces and certain communities, uh will push through their struggles for a very long time before they actually seek help. You know, they're afraid of being judged, they don't want to be seen as weak or unreliable. Uh they worry about what their employer might think, what it might mean for their career, whether this will follow them wherever they go. So they just keep showing up. You know, they white knuckle it. And by the time they finally do seek help, you know, their condition has often deteriorated deteriorated significantly.

Cynthia Carels

Yeah, and unfortunately, by that time, the condition can also be very sticky and considerably more resistant to treatment. So what might have been a relatively straightforward mental health condition if it was treated earlier can become very entrenched by the time someone actually gets to the point where they're not able to work anymore. They may have even been trying to manage treatment themselves with what we call maladaptive strategies that have actually made things worse in the big picture while they were very focused on just making it through, you know, one day or one night at a time. For example, we might see reliance on alcohol or cannabis to bring that cognitive noise down. And while that is completely understandable, that can spiral into addictions and other even bigger mental health concerns or physical health concerns, taking an already bad situation and unfortunately. Unfortunately, by trying to make it better or trying to make it palatable, it's it ends up making it worse, uh, without any medical records of the original complaint anywhere to be found because they've ever actually never really talked to a medical professional about it.

SPEAKER_00

And uh that's where it becomes a legal problem. So when that person eventually files a disability claim, the insurer will look at the timeline and uh raise exactly that question. You know, if you were truly disabled, why did you keep working? How did you keep working? Why didn't you complain about this sooner? You know, why didn't you get treatment sooner? And the delay that was ent you know entirely driven by stigma and fear gets reframed as evidence that the person wasn't actually that unwell. It's a deeply unfair argument, but it's it's one that we unfortunately see regularly.

Cynthia Carels

So the best answer to that argument from a legal standpoint is documentation. If a person can show through their own records, uh through their physician's notes, through any counseling or support that they might have accessed along the way, um, you know, anything that's showing they were struggling well before they stopped working, that can go a long way towards establishing timelines. Uh and it's also why we do encourage people, even if they're not sure they're going to be making a claim against a disability policy. Um, it's really important to talk to your doctor about what you're experiencing because having that stuff in the medical records uh early uh matters enormously. And of course, actually seeking evidence-based treatment from an appropriate professional is going to give people the best chance at making a good recovery, or at least getting these conditions under control and manageable uh so they can hopefully avoid ever needing to make one of these claims.

Warren Berg

So, what does a strong mental health disability claim actually look like and what does that file need to contain?

PTSD Details Delayed Onset Stigma

SPEAKER_00

The foundation is thorough, detailed documentation from treatment providers. You know, often in the form of medical legal reports from experts and consultation reports from specialists. Uh, and I want to be very clear about what detailed means, because this is an area where we see a lot of claims weakened by inadequate documentation. You know, a brief note that says patient has depression and cannot work is not sufficient. The insurer needs to see the specific diagnosis, how long the condition has been present, what symptoms the person is experiencing, and most importantly, what the functional impact of those symptoms is on the person's ability to work. So that last piece is critical. The connection between the diagnosis and the inability to work has to be explicitly drawn. Can the person concentrate for sustained periods? Can they manage the cognitive demands of their job? Can they handle workplace stress without their symptoms escalating? You know, can they interact reliably with coworkers, supervisors, or clients? Can they maintain a consistent schedule? If the answer to any of those questions is no, and with severe health conditions, the answers are often no across the board, you know, those limitations need to be spelled out clearly in the medical documentation.

Cynthia Carels

And ideally that documentation is going to be coming from multiple sources. So your family doctor's perspective is important, but if you're also seeing a psychiatrist or a psychologist, a social worker, a counselor, their observations matter too. And insurers are going to be paying close attention to whether the picture that's being painted is consistent across all of those providers. So when multiple treating practitioners are all saying the same thing about the severity of the condition and its functional impact, there's a much more compelling case than just, you know, a single note on a single day from one person.

Warren Berg

What about formal psychological assessments? Things like neuropsychological uh psychological testing. Uh, do these play a role?

SPEAKER_00

Yeah, they can be extremely valuable, uh, and in some cases they're really the key piece of evidence that makes the difference. So a formal uh neuropsychological assessment measures things like memory, attention, concentration, processing speed, uh, and executive function. And it does so in a way that uh produces actual scores and data that can be compared to established norms. You know, for conditions like severe depression or anxiety, where the person's cognitive functioning has been significantly impaired, that kind of assessment provides the objective evidence that insurers claim that they need. It translates uh what the person is experiencing subjectively into something much more measurable and documented.

Warren Berg

And and I understand that uh insurers sometimes also send claimants to their own medical examiners. Can you tell us more about how that process works and how people should handle it?

Cynthia Carels

So this is an area where people really need to be informed because they're um, you know, these insurance medical examinations can significantly affect the outcome of a claim, and most claimants go into them without any real preparation or understanding of what's happening or the purpose of this assessment. You know, many people show up for these appointments like they would to any other medical appointment with a treating doctor, thinking the doctor is going to help figure out what's going on, what's wrong with them, and what they can do to help. But here's the basic dynamic of an insurance medical examination. The insurer is arranging for the claimant to be examined by a physician of the insurer's choosing. The insurer is paying that physician, and the physician is being asked to provide an opinion on whether the claimant is disabled under the terms of their policy. And oftentimes these reports will suggest that the claimant is capable of returning to work, despite what you know we would consider to be a mountain of evidence to the contrary.

SPEAKER_00

Now, to be fair, not every insurance medical examiner is biased. There are many examiners who conduct those assessments professionally and reach fair conclusions. But the inherent uh structural conflict of interest is real. The insurer selects the the doctor, the insurer benefits if the doctor's opinion supports them, not having to pay the claimant. And uh running behind the scenes, the insurer is paying the doctor, and the doctor may want to get paid by that insurer again in the future. So, in our experience, IME reports and mental health cases very frequently minimize the severity of the condition, question the diagnosis, or suggest that the claimant is capable of more than their treating physicians believe. A single IME appointment, often lasting, you know, an hour or two, uh, gets used to override years of treatment records from people who actually know the claimant.

Cynthia Carels

And so if you're asked to attend an insurance medical ex uh exam, I highly recommend that you talk to a lawyer first. You want to know what your rights are going in. Uh, you want to be honest and accurate in how you describe your symptoms and limitations, and don't downplay what you're experiencing just because you feel uncomfortable or want to come across as coping well. We want that assessor to actually really understand what your good days are as well as your bad days. So it's important to describe the full range of how the condition affects you, not just how you happen to be feeling on that particular morning you're going to the IME.

SPEAKER_00

And and after the IME is done, uh get a copy of the report. You are entitled to it, then read it carefully. And if it contains inaccuracies, you know, if it misrepresents what you said, or if the conclusions don't reflect what the examiner actually observed, those discrepancies can and should be challenged. Your treating physician can respond to an IR IME report with their own detailed rebuttal, and uh that kind of back and forth medical evidence is something courts and arbitrators weigh carefully, and you know, a strong res response from a treating physician who has known the patient for years, uh it can carry enormous weight against a one-time IME assessment.

Warren Berg

Now you both mentioned treating physicians, so let's talk about treatment. Uh what role does treatment history play in a mental health claim? And what happens if somebody hasn't been able to access consistent care?

SPEAKER_00

So treatment history is enormously important, you know, both as evidence of the seriousness of the condition and often as a contractual requirement under the policy itself. Insurers want to see that you are actively engaged with your health care providers and making genuine efforts to address your condition. Gaps in treatment, you know, missed appointments, long stretches without seeing anyone, uh they get noticed and they get questioned. The concern from the insurer's perspective is that someone who truly couldn't work due to their mental health would be doing everything possible to get better. If the treatment record looks sporadic or incomplete, the insurer may use that to argue that the condition isn't really as severe as it's being claimed to be. Or, you know, that the claimant has made things worse due to noncompliance. But the reality of mental health treatment is complicated. Severe depression can make it genuinely difficult to do the most basic of things, including making a phone call to book an appointment. Anxiety can make certain forms of treatment feel overwhelming or impossible. You know, someone who's tried multiple medications without success may have reached a point of exhaustion and and hopelessness, you know, about whether anything that they do will help. So these are real and understandable situations. Uh the key from a claims perspective is that they need to be documented and explained, not just left as, you know, silent gaps in the record.

Strong Evidence For Mental Health Claims

Cynthia Carels

And access is also a massive issue. Mental health services in Alberta, and especially in smaller, more remote communities, uh, they can be extremely difficult to access. Wait lists for psychiatrists can be six months to a year or longer. Uh, psychologists are often not covered under provincial health coverage, meaning out-of-pocket costs that many people simply can't afford. Uh, and so if you are facing those barriers, it's also critical that you document those uh barriers yourself. So tell your family doctor, write it down. If you're on a wait list, keep records of when you were added and any follow-up that you've done. And if cost is a barrier to access, say so explicitly because that kind of documentation is going to tell a very different story than uh simply unexplained gap.

Warren Berg

So what happens when somebody feels embarrassed to tell their insurers that they maybe can't afford treatment? Does that hurt their case?

Cynthia Carels

Aaron Powell That is a very common concern, Warren. And the honest answer is that being upfront about it is almost always better than staying silent. Uh, but I understand the, you know, the concern and the embarrassment. Uh financial barriers to treatment are real, though, and and they are recognized. And we've had clients who've assumed that they would be penalized for not attending therapy, only to find out that actually taking the time to clearly explain that financial obstacle and demonstrating that you know what they were doing was within the means that they had available to them. We actually found that that strengthened their position instead of weakening it. Uh, because the insurers want to see evidence of genuine effort and good faith engagement with uh with the recovery process.

Warren Berg

Aaron Powell Now there's another tactic uh tactic that I've heard insurers use. Uh surveillance is maybe that's something that comes up in some of these mental health claims.

Cynthia Carels

Oh boy, it does. And it's something people should be aware of in any sort of disability or personal injury case at all. Uh insurers will sometimes hire investigators to conduct video surveillance of claimants, you know, following them in public, filling, filming them, going about their daily lives, doing their gardening. Uh, and that footage is then used to argue that the person is more functional than their claim might be suggesting. And in mental health cases, oh boy, this can be particularly misleading. If someone with a severe depression manages to get themselves to the grocery store on a good day or takes a short walk or attends a family event, uh, that footage could be presented out of context as evidence that the individual is perfectly capable of working. And it ignores everything else that happened before and after that moment. You know, it ignores the preparation and the recovery that went into that activity. It ignores the fact that doing something once, you know, on your own terms in a low pressure environment at your own pace is entirely different from doing it reliably every day in a structured workplace environment.

SPEAKER_00

So if you become aware that you're being surveilled, or if you suspect it, uh we'd recommend that you talk to a lawyer immediately. And in the meantime, the best approach is simply to live honestly. You know, don't perform disability, but also don't push through your limitations to prove something either. If you're having a difficult day, rest. If you feel, you know, genuinely feel well enough to go for a short walk or visit a family member, that's okay. But be aware that what you do in the public may be observed or surveilled. The key is that your daily activity should be consistent with what you've reported to your to uh your insurer. Inconsistency is what creates problems.

Cynthia Carels

Yeah, and further to this discussion about surveillance uh is something a lot of people might not even give a second thought about, which is their social media activities. Uh and in the world of personal injury and disability law, and and and quite frankly, a whole bunch of other areas of litigation these days, uh, we call social media the private investigator that never sleeps. Uh these days, people are putting massive amounts of free surveillance evidence online. And, you know, since we all tend to carefully curate our public presentation to the world through our social media, that content can seriously distort how disabled or depressed or otherwise injured a person might actually appear. And don't just assume that if you've set your profile to private, that you've sufficiently protected yourself from having a social media account used against you. There is an increasing body of law where courts are ordering considerably broader disclosures of social media content than injured people were ever expecting. So when Ian says that consistency is the key to credibility, that truly applies across the board. So I encourage my clients to be very careful of generating content online that might be inconsistent with what's being reported to their treatment team and their insurer.

Warren Berg

Good to know. So what should somebody do if they think they've done everything right, they've got the documentation, they've been engaged with treatment, there isn't any damaging surveillance or social media, and they still get denied.

SPEAKER_00

So the first and most important thing is don't accept the denial as the final word. These denials are common, but they are also frequently and successfully challenged. The denial letter is your starting point. You know, read it carefully because it tells you exactly what the insurer's objection is. Is it a documentation gap, a definition dispute, a procedural issue? Each of those uh uh different types of uh denials requires a different response, and identifying which one you're dealing with is the first step towards forming a strategy.

Warren Berg

And this is probably a good time to talk to our listeners about how they can get in touch with you if they need to talk to a lawyer about a personal injury claim or a disability claim. What is the best way to connect with you?

Cynthia Carels

So the easiest way is to check out our website at wearbowen.com. So that's w-e-i-r b-o-w-en.com. And on our contact us page, there is a form you can fill in, and our reception staff will make sure that your inquiry gets to the right people.

Warren Berg

And what if the internet isn't an option?

SPEAKER_00

So we also frequently take what we call cold calls. So uh to access us over the phone, just call our main reception line at 780-424-2030, and our receptionist can get you in touch with one of our team members.

Insurance Medical Exams What To Do

Warren Berg

This is Ask the Lawyer on Windspeaker Radio, C FWE and CJWE. I'm your host, Warren Berg, and joining us once again today, Cynthia Carrolls and Ian Mirror Ian Miller of Weird Bowen L L P in Edmonton. That's W-E-I-R-B-O-W-E-N 780-424-2030 or online at Weirbowen.com. And today we're talking about disability law. And so far we've primarily focused on mental health disability claims and the particular challenges that they present. What other kinds of claims tend to lead to struggles within insurers?

Cynthia Carels

So we want to turn to another category of claims that face many of the same conditions, which are often called invisible disabilities. So these are conditions like fibromyalgia or chronic fatigue syndrome, chronic pain. And again, these are disabling conditions that aren't going to show up on an X-ray or MRI.

SPEAKER_00

Yes, the term invisible disability refers to conditions where the person's suffering and functional impairment are real and often severe, but where there's no objective visible signs of the illness, and where conventional medical testing doesn't produce the kind of findings that would make the disability immediately obvious to an outside observer. So the person looks fine, their lab work is normal, they may even have days where they feel relatively better. But underneath that, they're managing conditions that can make sustained employment genuinely impossible.

Cynthia Carels

And in the legal context, that invisibility can be a real problem. Insurance companies, as we mentioned earlier, are oriented toward objective evidence. They want something they can point to, a scan, a test result, a measurable finding. And with conditions like fibromyalgia or chronic fatigue syndrome, that evidence just doesn't exist in a conventional sense. The diagnosis is clinical. It's based on symptoms, it's based on patient history and a physician's assessment, and even sometimes trial and error where other conditions that can have been tested for, but they've been ruled out. And insurers can really lean on the absence of what they describe as hard evidence to question whether the disability is actually legitimate.

Warren Berg

So let's go through some of these conditions specifically, starting with fibromyalgia. First of all, what is it and why is it such a challenging basis for a disability claim?

SPEAKER_00

So fibromyalgia is a chronic condition characterized by widespread musculoskeletal pain, fatigue, sleep disturbances, and what's often described as cognitive fog, which is difficulty concentrating, remembering things, and processing information. So it's a real recognized medical diagnosis with established clinical criteria, but it's also a condition that has historically been misunderstood, dismissed, or minimized, you know, including within the medical community itself and uh certainly within the insurance industry. So again, there's no blood test for fibromyalgia, there's no imaging findings. Uh the diagnosis is uh is made based on the patient's reported symptoms and clinical examination using criteria that have been developed and refined over decades of research. A knowledgeable physician can make a confident diagnosis, uh, but insurers sometimes try to leverage the absence of a definitive biomarker to suggest that the condition isn't real or that it isn't as severe as the claimant says. And, you know, that's an argument that we have to push back on hard.

Cynthia Carels

In fact, blood tests that don't find the objective biomarkers of other clinical illnesses is part of the way that fibromyalgia itself gets diagnosed. As the treatment team tries to rule out, you know, autumn autoimmune diseases or even allergic responses. What makes fibromyalgia particularly challenging from a claims perspective is honestly the variability. It is a not static condition. Um someone might have days where they're managing reasonably well, and other days where they can barely function, and insurers sometimes point to that variability as a reason for skepticism, as if the fact that a person has some good days means they're not really disabled. But that is not how this condition works, and it's not, in our opinion, a legitimate base for denial. Um a disability doesn't have to be constant and unrelenting to be real. What matters is whether, you know, across the full picture of the condition, if the person is able to sustain reliable, consistent functioning uh that uh an employer would require.

Warren Berg

Okay, so what about something like chronic fatigue syndrome? That's another condition I understand is frequently disputed.

Treatment Gaps Cost Access Barriers

SPEAKER_00

Yeah, so chronic fatigue syndrome is uh, in many ways, the most misunderstood condition that we deal with in this area. So it's characterized by profound, uh debilitating fatigue that is not relieved by rest, and that is often worsened by physical or mental exertion. So it's not just being tired, it's a condition where pushing through and trying to do more can actually make you significantly worse. And yet, because the person may not look sick, and because the condition has historically dismissed in some medical circles as uh being psychosomatic, it continues to face skepticism from insurers. But chronic fatigue syndrome is recognized by the World Health Organization and by medical authorities across the world as a serious physical illness, and that recognition needs to be reflected in how these claims are handled.

Cynthia Carels

Yeah, and I want to add that the population of people dealing with chronic fatigue syndrome has grown significantly in recent years, in part because of the recognition that some people who had serious viral illnesses have gone on to develop persistent debilitating symptoms. Uh so, for example, since the pandemic, uh, there has been a lot more research on this one, as certain people have been left with what's being called long COVID, which has led to disabilities many months after a COVID-19 infection. It's interesting because long COVID isn't even necessarily connected to how bad the initial COVID infection even was. And there are cases of it arising after some relatively mild early symptoms. So this is a growing reality in the disability world, and it's one our group at Weir Bowen is very much aware of, and we are well equipped to handle.

Warren Berg

Okay, so chronic fatigue is one thing, but chronic pain more broadly, that likely cuts across a lot of different conditions and situations, I would imagine, anyway. Is that correct?

SPEAKER_00

Yeah, chronic pain is a very common thread running through all of these tricky disability claims. It's a symptom that can arise from uh many different underlying conditions injury, disease, nerve damage, inflammatory conditions. You know, chronic pain. Can stem from all of these and more. And what makes it so difficult in the disability context is that pain is inherently subjective. You know, there's no instrument that measures how much pain a person is in. You can't see it, you can't quantify it objectively. The person's report of their own experience is the primary source of information, and that's exactly the kind of evidence insurers are most likely to question.

Cynthia Carels

And we see chronic pain claims come to us from people in all kinds of occupations and situations. Someone who was injured in a motor vehicle accident and, you know, never fully recovered, could be someone managing a degenerative condition that has progressed to the point of becoming disabled, someone whose pain began after maybe a surgery that didn't go quite as planned. In all of these situations, the challenge is the same, and that is building a file that actually translates that person's lived experience of pain into a documented, evidence-based case for a disability claim.

Warren Berg

And I would imagine the you look fine problem is just as significant with chronic pain as it is with mental health.

SPEAKER_00

Yeah, it's even more pronounced in some ways. At least with mental health conditions, there's a growing public understanding that someone can be seriously unwell without it being visible. With chronic pain, the gap between appearance and reality is often even harder for people to accept. Someone managing severe fibromyalgia might look perfectly healthy on a given day. You know, they're dressed, they're out, they're interacting with people. But what an outside observer doesn't see is that it took them three hours to get ready, that they'll spend the rest of the day in bed recovering, you know, that they've canceled everything else in their week to manage this one outing. The surface appearance uh appearance tells you almost nothing about the actual burden of the condition.

Cynthia Carels

And insurers are very skilled at using those surface experiences to their advantage. So surveillance footage of someone walking to their car or carrying like groceries can get presented as evidence that this person is physically capable of working without any context about how long that particular uh activity on the surveillance actually took, uh, what it cost that person in terms of their pain and recovery, or how representative that one little snapshot in time is of their daily functioning. Uh so it can be you know misleading uh in terms of evidence, and countering it's going to require some careful, thorough documentation from people who actually know that claimant's condition.

Warren Berg

So, how do you actually build a compelling case around a condition that can't be directly measured?

Surveillance And Social Media Risks

SPEAKER_00

Starts with the treating physicians report, and the same principles apply here as with mental health claims. It needs to be detailed, specific, and explicitly connected to the person's ability to work. Not just the patient has chronic pain, but you know, something along the lines of this patient with this specific presentation and these documented functional limitations is unable to perform the following tasks for the following medical reasons. So the more individualized report uh that the report is, the harder it is for the insurer to hide behind generalities about the condition. Uh beyond the treating physician, specialist opinions can also be critical. So a rheumatologist for fibromyalgia, a neurologist or pain specialist for chronic pain, a specialist, you know, in the relevant area for chronic fatigue syndrome. These opinions carry significant weight because they come from someone with deep expertise in a specific condition, and they can directly address the kinds of technical arguments insurers raise about, you know, whether the diagnosis is legitimate and whether the level of impairment is consistent with the medical evidence.

Cynthia Carels

And then there's the functional capacity evaluation, which I think is one of the most powerful tools that's available in these kinds of cases. So an FCE, that functional capacity evaluation, it's a structured assessment that's typically conducted by a professional known as an occupational therapist or perhaps a physiotherapist, and it actually measures what that person can do physically. How long can they sit, how long can they stand or walk, how much can they lift safely, how do they perform over an extended period of assessed activity? And what sort of impact does the testing itself have in the days that follow? And this is objective, observed evidence that's documented by a trained professional, and it produces a concrete picture of functional capacity that directly answers the question of whether or not that person can actually work.

Warren Berg

Can you maybe tell us a little bit more about what that assessment actually involves? So just so our listeners who might be facing one know what to expect.

Cynthia Carels

Yeah, for sure. So a functional capacity evaluation typically takes place over one or two days. Uh the evaluator, like I said, usually an occupational therapist, is going to be putting that position or that person through a series of structured physical tests that are designed to measure their actual capacity in a controlled setting. So they're going to be testing things like how long the person can sit without needing to change positions, how long they can stand, how far they can walk, how much they can lift and carry safely, and how well they can manage tasks involving reaching, bending, fine motor control. And they're also observing things like pain behaviors, uh, fatigue, uh, and how that person's capacity changes over the course of the assessment period. And the results are then compiled into a report that categorizes the person's functional capacity, things like whether they can perform maybe a sedentary, a light or medium work or for how long. And that report becomes a critical piece of evidence in the disability claim because it's based on observed performance rather than an individual self-report. Uh so for someone whose condition is being questioned, it can provide exactly the kind of objective documentation that an insurer uh claims to need. And, you know, I always tell my clients there are a lot of smoke and mirrors that are built into these assessments, um, as well as, you know, some more kind of in-your-face reliability checks throughout the process as well. And those are really intended to weed out people who might be trying to game the system.

SPEAKER_00

So one important caution though, so for people with chronic fatigue syndrome in particular, a standard two-day FCE can actually cause a significant post-exertional crash. The evaluation itself can make someone with that condition considerably worse. So this is worth uh discussing with your physician and your lawyer before agreeing to one because there may be ways to modify the assessment protocol or to document uh the post-evaluation impact in a way that actually strengthens uh the claim.

Denials How To Respond

Cynthia Carels

You know, and that piece is super important, Ian, because so many of our clients are very stoic people who do try their best on these assessments, but then they pay for it dearly in the days that follow. And so that's critically important information for the assessor to have because it demonstrates that rallying to power through a demand might work in isolation. You might be able to do it once or twice, but it is not a safe or sustainable person or pattern for that person to have to do every day.

Warren Berg

What about that uh insurance medical examiner issue that we discussed in the mental health segment? Does that come up with these invisible physical disabilities too?

SPEAKER_00

Very much so. So with invisible disabilities, the IME physician has a lot of latitude to dismiss or minimize what they're seeing. So IME reports on fibromyalgia and chronic fatigue syndrome cases can frankly be a little bit offensive to read. They can treat a clinically well-supported diagnosis as questionable, you know, suggest that the person's limitations are exaggerated or psychosomatic, and conclude that the person is capable of returning to work based on a brief examination that bears very little resemblance to, you know, that person's actual daily experience.

Cynthia Carels

Or what drives me super crazy is suggesting that a bit of weight loss and exercise is all that person needs to recover their functionality, as opposed to, you know, acknowledging that weight gain and energy depletion can actually be compounding consequences of the underlying condition. But the response to a poor IME report is honestly it's the same as with mental health. Your treating physicians can respond in writing, your specialist can provide rebuttal opinions, and a lawyer can help you understand whether the IME report reflects a genuine independent assessment or if it reflects that you know systemic conflict of interest that we had talked about earlier that's built into how these assessments are structured. And courts are well aware of that IME dynamic, and a biased or a superficial IME report that contradicts years of careful treatment records is often going to carry less weight than the insurer might hope.

Warren Berg

What about treatment for these conditions and the access and cost challenges that we talked about earlier?

How To Reach Weir Bowen

SPEAKER_00

So insurers want to see active, consistent engagement with treatment. For chronic pain and fatigue conditions, that might include physiotherapy, pain management programs, occupational therapy, medications, and uh potentially psychological support, you know, because chronic pain and mental health are often deeply intertwined. So if the treatment record shows long gaps or incomplete follow-through, the insurer may use that as a grounds to question uh the severity of the condition. But again, the reality is complicated. You know, chronic pain is exhausting, managing it takes enormous energy, you know, when energy itself is already depleted. Treatment can be painful in itself, you know, physiotherapy, for example, can cause significant short-term exacerbation of symptoms. And for these conditions, pushing too hard with physical rehabilitation can make the person significantly worse. So what's appropriate treatment for one person may not be appropriate for another, and that nuance needs to be reflected in the documentation.

Cynthia Carels

And you're right. Access and cost are again significant barriers in this area. So pain specialists in Alberta often have long wait lists. Physiotherapy, again, generally not covered by Alberta Healthcare unless you're in an acute phase of recovery or a few other narrow conditions where people might qualify for a handful of appointments. Uh privately funded occupational therapy can be expensive too. And for someone who's already managing a reduced income, um, you know, if they're relying on disability benefits, or if they've been denied and have no income at all, those costs can be genuinely prohibitive. So again, if cost or access is limiting your ability to follow through with treatment, get it documented. Tell your doctor, tell the insurer. Uh, don't let that just sit as an unexplained gap.

Warren Berg

Aaron Powell What are some of the other specific arguments that insurers tend to make when denying these kinds of claims, and how do you counter them?

SPEAKER_00

So another common argument is that the person could do some other kind of work, you know, lighter duties, a desk job, something less physically demanding. This comes up particularly when the any occup any occupation definition applies. Uh the counter to that is addressing not just the physical limitations, but the cognitive and functional ones as well. So chronic pain and fatigue conditions affect concentration, memory, processing speed, and reliability. You know, not just physical capacity. A person who can barely function on a bad day, you know, who can't predict from one day to the next how they'll be feeling, who needs to rest repeatedly throughout the day, that person cannot reliably sustain any occupation, regardless of how sedentary it might be.

Cynthia Carels

And we sometimes see insurers argue that because a person has some capacity, you know, they can drive short distances, they can do like grocery shopping, they can occasionally socialize, um, that they must be capable of working at something. And this argument conflates limited, controlled, and self-managed activity uh with the sustained, structured, and externally demanding requirements of employment. And they are just simply not the same thing. Being able to do something occasionally and on your own terms is very different than being able to do it reliably for eight hours a day, five days a week under the pressure of workplace expectations.

Warren Berg

Aaron Powell So what's your advice for somebody who is in the middle of one of these claims and feeling like the insurer just isn't taking their condition seriously?

SPEAKER_00

Uh get legal advice. That's the most important thing. Not because a lawsuit is necessarily the right next step in every case, you know. In fact, it it may not be. But because understanding your rights, understanding what the ob uh you know the insurer's obligations are, and having someone assess the strength of your file uh can fundamentally change how you approach the situation. So we're Bowen, you know, that first conversation is free. There's no obligation, and it can make an enormous difference uh with respect to what happens next.

Invisible Disabilities And Objective Proof

Cynthia Carels

And don't stop advocating for yourself medically. Keep seeing your doctors, keep pursuing treatment uh within your means and within what your body can safely manage. And ask your physicians to be specific and detailed in their documentation. And if a specialist referral has been recommended, follow through on it even if the wait list is long. Because being on the wait list demonstrates that effort and good faith. And every piece of evidence you can add to your file is another piece of that foundation of your claim.

SPEAKER_00

And if a claim has already been denied, don't give up before uh speaking with a lawyer. When we take on files like these, we do our best to move them as quickly as we can. We gather the evidence, we engage the experts we need, and we pursue the claim with advanced knowledge of the kinds of arguments insurers make. We've seen them over and over, and we know how to counter them. These conditions are real, you know, the suffering that they cause is real, and the impact on a person's ability to work is real. The fact that they're harder to prove than a broken bone doesn't make them any less legitimate, and it doesn't mean that the claim can't be won.

Warren Berg

And that's such an important message, and I think that it's one that a lot of our listeners needed to hear today, because the road it isn't always easy, and it it sounds like uh with the right support, it's a road that can be traveled.

Cynthia Carels

Yeah, if our team thinks there's a pathway, we're even gonna walk away with you.

Warren Berg

So, Cynthia, if somebody's dealing with a disability claim right now, whether they're just starting out or whether they've already been denied, what is the first step?

Cynthia Carels

So call us or go to our website. It it really is that simple. Um, at Weirbowen, every disability consultation is free. There is no charge for that first call, uh, no obligation afterward either. So we're going to take some time to gather that basic information about your situation, the nature of your disability, the timelines, uh your work history, what the insurer said, and we're gonna give you an honest, informed advice about what your options are. Sometimes that means opening a file and pursuing a claim, but sometimes it just means practical guidance to help you act on your own. Um and either way, you're gonna leave the con the conversation better informed than you were before.

Fibromyalgia What Insurers Get Wrong

SPEAKER_00

And I want to reinforce something that's important for anyone who might be hesitating. You know, we work on contingency for disability files. So that means no upfront costs, no retainer, no hourly bills to pay along the way when you know money is already tight. We only get paid if you get paid. So for people who are already dealing with reduced or no income because of a disability, that removes the uh financial barrier to getting proper legal representation. So once again, where can listeners find you? Uh so you can find us online at weirdbowen.com. That's W E-I-R-B-O-W-E-N.com. Uh there's a contact form right on the website, or you can call us directly at 780-424-2030. Uh someone will get back to you quickly, and that first conversation won't cost you a thing.

Warren Berg

We've covered a lot of ground today in the April edition of Ask the Lawyer with Cynthia Carrolls and Ian Miller of Weird Bowen, L L P in Edmonton. Once again, if you need more information, go to WeirdBowen.com, W-E-I-R-B-O-W-E-N. Their phone number 780 424 2030. You can also find a link to Ask the Lawyer on our homepage, where these shows will be available to stream on demand. Our thanks once again to Cynthia and Ian.

Cynthia Carels

Yeah, thanks, Warren. Uh, this is exactly the kind of conversation we believe matters. Getting real information to real people, hopefully at times when they when they actually will need it.

SPEAKER_00

Couldn't agree more. Thanks for having us.

Warren Berg

And we look forward to learning much more through this series, which takes place here on the last Saturday of every month, here on Win Speaker Radio, CFWE and CJWE.