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A step-by-step on how and when to apply for long-term disability benefits in Ontario.
Long-term disability insurance is typically provided through your employer as part of a group benefit plan, or purchased individually through a broker or an association/organization. Long-term disability replaces a portion of your monthly salary either in a predetermined specified amount, or as a percentage of your salary, up to a certain amount. Long-term disability coverage is available to policyholders if he or she becomes unable to work for a prolonged period of time due to a chronic illness, disability, disease or injury.
Disability benefits in Ontario are normally obtained two ways.
The first is through group plan, available through an employer or association. Long-term disability available through group benefit plans generally offer more limited protection, but at a lower cost of the insured employer. If you obtain long-term disability benefit coverage through your employer as part of a group benefit plan, many employers will pay some or all of the cost of the premiums – but remember, group coverage ends when you change jobs.
Disability benefits in Ontario can also be purchased individually and not part of a benefit plan. Individual long-term disability policies are normally available directly from an insurance company or through a licensed broker, on a client by client basis. Individual long-term disability policies normally offer more extensive protection, but at a higher cost to the insured. Individual disability plans tend to give people the most flexible and comprehensive coverage. Benefits with individual plans are tax-free because premiums are typically paid with after-tax dollars.
You will typically be dealing with one of the 16 disability carriers that represent approximately 99% of the Canadian disability insurance plan market for group and individual insurance plans. These carriers are:
Blue Cross Life;
Pacific Blue Cross (BC Life);
Sun Life; and
There are no specific conditions that are set out in long-term disability policies. However there could be medical condition exclusions underwritten in your policy. Group plans are not individually underwritten at the time the plan is issued to the employer – therefore you likely won’t see any excluded conditions with your disability plan issued through work. However, your group disability carrier might argue that you suffer from a “pre-existing condition “that disqualifies your entitlement to long-term disability benefits. This entitlement will normally happen if you have had disability coverage for a short period of time – normally less than 12 months.
Excluded medical conditions are normally a part of individual disability policies given that the plan is underwritten at the time of application in the individual purchasing the disability plan will likely go through intense medical screening. It’s important that you check your long-term disability policy concerning whether or not certain conditions are excluded at the time the policy was issued.
We have helped recover wrongfully denied disability benefits for individuals that suffer from medical conditions, such as:
This list is certainly not exhaustive. We have assisted disability claimants who have suffered various medical conditions since 2003.
Remember, if you are sick or hurt and you need to apply for long-term disability benefits, you must first check with your HR department, plan sponsor or your benefit policy or booklet to determine what your elimination period is. You can only apply for long-term disability benefits at the completion of your elimination period.
The elimination period is a term that the insurance industry uses to refer to the period of time between the onset of your disability and the time you receive long-term disability benefits. It is a “waiting period” from the time you’re illness or disability begins. The elimination period is also sometimes known as the qualifying period. Elimination periods could vary in length, however the most common elimination period is 90 days or 120 days. Typically, disability insurance premiums are cheaper if the elimination periods is longer.
During the elimination period, a claimant would apply for short-term disability, or in the alternative, unemployment insurance sickness benefits if their employer does not offer short-term disability coverage. Once the elimination period is expired, you would then apply for long-term disability monthly benefits. In order to do so, you must speak to your HR department or plan sponsor. If you have an individual plan, you would contact your broker directly.
Typically for most insurance companies, the application procedure for long-term disability benefits is quite similar:
Plan Member or Employee Statement – The plan member or employee statement begins the claim submission process. You would provide to the insurance company a Plan Member Statement or Employee Statement which confirms and explains your condition, and how it developped or progressed. The statement provides a general overall medical history and an explanation as to any income or sources of income or benefits that you would receive well on medical leave.
The statement would also require you to describe when you’re symptoms first appeared so that a date of onset of disability could be determined. You would also be required to provide information as to whether or not you ever suffered the same illness or disability. This is particularly important if you are new plan member. The statement would also require you to document a summary of treatments you are receiving, medications you are taking, any rehabilitation that you are participating in, a summary all doctors you’ve seen, hospitals you have attended and whether or not you suffer an injury that occurred in the workplace.
Some Plan Member Statements or Employee Statements require you to provide direct deposit authorization.
Attending Physician Statement – You are also required to submit an attending physician statement as part of your long-term disability application package. It helps your disability carrier understand the nature of your overall condition and disability. Always make sure that your doctor clearly explains your diagnosis or disability (and also explains all of your diagnosis or disabilities if there are multiple issues or multi-system trauma – typically attending physician statements do have primary secondary diagnosis options to fill in. Make sure your doctor provides copies of all test results, imaging, specialist reports etc. Typically doctors will fill out a form, or PDF form, and most do not bother or have the time to include any clinical documentation with their statement (particularly without your authorization) when in fact, the more information they provide, the better. It’s very important that you speak to your doctor and make sure that he or she provides all clinical findings, observations and diagnoses to your disability carrier so they can in turn better adjudicate the claim with full and complete knowledge of your medical issues.
If you’re applying for long-term disability benefits due to a mental health issue, there are certain carriers that provide modified attending physician statements is geared towards these particular findings.
Some insurance carriers will have attending physician statements that are geared towards orthopedic injuries, musculoskeletal issues, cardiac issues, mental illness, cancer and other particular and common disorders and diseases.
Employer statement – often times your employer will be required to provide information to the disability carrier in terms of your monthly earnings and other financial information needed to assess the exact amount you may be entitled to monthly.
Interview by your Appointed Case Manager – approximately 10 days after you submit your application and attending physician statement, an adjuster, or disability claims adjudicator will be assigned to your case. More often than not, your adjuster or representative will contact you by telephone to obtain information from you concerning your job, your education and employment history, your overall medical history and information concerning your current disability.
In order to qualify for long-term disability benefits, you must suffer a total disability. Most, if not all long-term disability carriers, have their own definition of what they consider to be a total disability – but typically, a total disability means two things:
Own Occupation – During the elimination and the following 24 months after you may qualify for disability benefits if you are considered to be totally disabled from performing the substantial duties of your own job (known as the own occupation). In other words, benefits may be recovered if you unable to perform all the substantial and material acts necessary of your own usual occupation. If you cannot substantially carry out all the normal tasks involved in your own occupation, then you will have sustained a total disability and receive your monthly disability benefits.
Any Occupation – After 24 months there is an important juncture in most disability policies – meaning the definition of total disability changes (what your adjuster may call the COD or change of definition) from own occupation to any occupation. The “any occupation” definition is the most restrictive definition of disability, from the insured’s perspective. It means that the insured will be considered totally disabled if he or she cannot perform the duties of “any occupation” for which he or she is reasonably suited by education training or experience. You as a claimant bear the onus of establishing, on a balance of probabilities, that you are disabled from working at any occupation for which you are reasonably suited by education training and experience.
Even if a claimant is able to perform only minor functions of the job, our Courts have told us that he or she will be nonetheless found totally disabled. An ability to perform one or more substantial aspects of the occupation will not necessarily disqualify the insured from disability coverage.
Total disability in the context of his or her own occupation does not require that an insured person be completely incapable of any activity, but rather it is established where the insured is incapable of engaging in at least some of the important duties of a given occupation. A claimant need not be totally helpless.
Unless your policy is a for a pre-determined specific amount (i.e. the same non-indexed amount every month) your disability payment will be based on a specific percentage of your monthly earnings at the time that you began to suffer your disability. The percentage will be stated in your actual policy or benefit booklet provided to you by your employer.
Normally with most carriers, disability payments should start the day following the completion of your elimination period.
In most cases yes. Most policies issued in the last 8 to 10 years require you to submit an application for CPP disability benefits
All source maximum is a common feature in most long-term disability policies. The all source maximum is designed to make sure that claimants do not receive more income while on disability than they would if they were actively working. There needs to be some incentive for the insured to get back to work. Normally (not always – check your policy) the all source maximum clause in disability policies state that while receiving long-term disability benefits, a claimant’s net income cannot exceed 80 to 85% of their pre-disability net income.
If you paid your premiums with after-tax dollars, the benefits are tax-free. This is normally the case with individual disability plans.
If the premiums are paid out of pre-tax income, the benefit is normally taxable.
If your employer pays part or all of the premium as part of your employment benefit package, your disability benefits will be subject to income taxes. However, in certain circumstances the benefit might be non-taxable provided the amount of the premium is treated as a taxable benefit to the employee and reported on a T-4 tax information slip.
If you are not represented by our disability lawyers then yes, you should. Often times disability carriers need permission to obtain clinical information from your first party providers to better help them assess your claim. When you sign an authorization, you are giving your disability carrier permission obtain your health related information from your treatment providers, your plan sponsor, hospitals, rehabilitation clinics etc. If you are represented by our law firm, then your disability carrier should not be sending you correspondence or speaking with you.
The cost of living adjustment, otherwise known and most policies as COLA provides for regular increase in the monthly income benefit coverage, based on a formula that reflects cost-of-living increases.
If you qualify for disability benefit and then try to go back to work, most disability insurance policies will typically contain a provision that waives the re-commencement of a new elimination period after a brief recovery followed by a recurrence of the same or a related disability. For example, if a claimant suffers a heart attack which leaves her totally disabled for six months, she receives long-term disability benefits after her elimination period, and eventually tried to return to work. After several months, she suffers another heart attack the leaves her totally disabled once more. In situations like this, most insurance companies will administer the claim as a continuance of the original claim (recurrent disability) and waive the elimination period. Most, if not all of the disability policies have a six month recurrent disability period.
You should continue to receive long-term disability benefit payments monthly so long as you meet the definition of total disability, both pre-and post-change of definition.
Typically, your benefits will end once you reach the age of 65, although you should check your individual booklet or speak to your HR manager. Policies vary from insurance company to insurance company.
The frequency of clinical records being requested is up to your individual claims adjuster. However, if you suffer a total disability that prevents you from working in any occupation for which are reasonably suited by education training and experience (i.e. after 2 years) most disability insurance companies will request updated medical records approximately once every 12 months.
Absolutely. it happens everyday. Often times, adjusters will unilaterally decide to wrongfully cut off or deny disability benefits based on their own “medical judgment” of your condition or after an independent assessment by one of “their own” doctors. Your benefits can also get cut off if you’re not following an appropriate treatment plan is set out in your policy, you are sent prison, your absent from Canada, you do not provide enough medical documentation, you do not apply for CPP, your adjuster is put surveillance on you that she been consistent with your impairments, or, near the shift of definition because your adjuster does not believe that you are unable to perform any occupation. Most times however, it is adjusters that simply think “it’s time” to cut you off.
If your insurance company refuses to pay your disability claim, or cuts off your monthly benefits because they “decide” you can go back to work, you have the right to internal appeals. Typically internal appeals will require you to submit additional medical documentation to help prove your entitlement to disability benefits. Often times however, the final decision makers in the appeal process will not reverse the original adjudicator’s decision to deny long-term disability benefits.
You have the full right at any time after the original letter of denial to contact a disability lawyer. We always recommend that you start the disability claims process with a lawyer, rather than appealing your claim with your insurance company internally (that being said, there are certain policies that mandate that you go through the appeals process first).
When you retain our Ontario disability lawyers, we insurer to obtain all your clinical documentation, as far back as possible, which is normally 7 to 9 years with medical providers. If you have suffered a long-standing mental illness or mental condition, or you have been through a traumatic experience in the past, it’s important that that information is properly presented to your insurance company. It’s very difficult for a claimant to order each and every clinical record on his or her own, and its best left to disability lawyers to do this for you. We would then compile your clinical file, and retain the appropriate experts nationwide to provide a specialized opinion on your case which, will indicate whether or not you are totally disabled as per your own occupation, or any occupation as provided for in your policy. The process is complex and difficult, and it’s certainly best left to experienced disability lawyers to undertake on your behalf.
It’s important to understand that if you been denied or cut off your long-term disability benefits, it is not the end of the road. You have the full right to retain a disability lawyer to help protect your rights. Disability laws are very complicated and continually evolving law. If you been denied or cut off your disability benefits, it’s important that you retain a disability lawyer with experience in disability law, and who focuses nearly or exclusively on disability insurance cases.
Matt Lalande has been litigating disability cases since 2003 and is recovered millions in wrongfully denied disability benefits for claimants all over Ontario. If you been denied or cut off your disability, call us today no matter where you are in Ontario TOLL FREE at 1-844-Lalande, or local at 905-333-8888 and schedule your free consultation today. Alternatively, please speak to our live chat operator or fill in a contact form and somebody from our office will get right back to you.
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