By Matt Lalande in Uncategorized on September 02, 2024
Navigating the process of applying for long-term disability benefits in Ontario can feel overwhelming, especially when you’re already dealing with the challenges of a severe injury or illness. Understanding each step and knowing what to expect can significantly reduce stress. This guide is designed to walk you through the entire application process, offering clear, practical advice to help you secure the benefits you deserve. Whether you’re just starting your application or need guidance along the way, this resource will provide you with the essential tools and knowledge to successfully navigate the system.
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 due to a chronic illness, disability, disease or injury.
Disability benefits in Ontario are normally obtained in two ways.
The first is through a group plan, available through an employer or association. Long-term disability available through group benefit plans generally offers more limited protection but at a lower cost to 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. They 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 deal with one of the 16 disability carriers representing approximately 99% of the Canadian disability insurance plan market for group and individual insurance plans. These carriers are:
Assumption Life;
Blue Cross Life;
Co-operators Life;
Desjardins Financial;
Empire Life;
Equitable Life;
Great-West Life;
Industrial Alliance;
Humania;
La Capitale;
Manulife;
Pacific Blue Cross (BC Life);
RBC Life;
SSQ;
Sun Life; and
Wawanesa Life.
There are no specific conditions that are set out in long-term disability policies. However, medical condition exclusions could be underwritten in your policy. Group plans are not individually underwritten when 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 normally happens if you have had disability coverage for a short period – normally less than 12 months.
Excluded medical conditions are usually a part of individual disability policies because the plan is underwritten at the time of application, and the individual purchasing the disability plan will likely undergo intense medical screening. You must check your long-term disability policy to see whether or not certain conditions were excluded when the policy was issued.
We have helped recover wrongfully denied disability benefits for individuals who suffer from medical conditions, such as:
Remember, if you are sick or hurt and need to apply for long-term disability benefits, you must first check with your HR department, plan sponsor, or benefits policy or booklet to determine your elimination period. You can only apply for long-term disability benefits after your elimination period.
The elimination period is a term the insurance industry uses to refer to the period between the onset of your disability and the time you receive long-term disability benefits. It is a “waiting period” from when your 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 are longer.
During the elimination period, a claimant would apply for short-term disability or unemployment insurance sickness benefits if their employer does not offer short-term disability coverage. Once the elimination period has expired, you will apply for monthly benefits for long-term disability. You must speak to your HR department or plan sponsor to do so. 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 the insurance company with a Plan Member Statement or Employee Statement confirming and explaining your condition and how it developed or progressed. The statement provides a general overall medical history and explains any income, sources of income, or benefits you would receive well on medical leave.
The statement would also require you to describe when your symptoms first appeared so that a date of onset of disability could be determined. You would also be required to provide information on whether you ever suffered the same illness or disability. This is particularly important if you are a 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 of all doctors you’ve seen, hospitals you have attended and whether or not you suffered 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 must also 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. Ensure 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. You must 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 better adjudicate the claim with complete knowledge of your medical issues.
If you’re applying for long-term disability benefits due to a mental health issue, certain carriers provide modified attending physician statements geared toward 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 joint disorders and diseases.
Employer statement – often, your employer will be required to provide information to the disability carrier regarding 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 ten 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.
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, 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 your own occupation). In other words, benefits may be recovered if you are unable to perform all the substantial and material acts necessary for 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 your 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 nonetheless be 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. Still, rather, it is established where the insured is incapable of engaging in at least some of the essential duties of a given occupation. A claimant need not be totally helpless.
Unless your policy is for a pre-determined specific amount (i.e. the same non-indexed amount every month), your disability payment will be based on a particular percentage of your monthly earnings when you began to suffer your disability. The rate 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 apply for CPP disability benefits. Most disability carriers will pressure you around the two-year mark to apply for CPP Disability so that they can get the offset. Remember – you cannot receive both LTD and CPP.
To answer this question, you must know the “All-source maximum.” All-source maximum is a common feature in most long-term disability policies. The all-source maximum ensures 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 return to work. Usually (not always – check your policy), the all-source maximum clause in disability policies states that while receiving long-term disability benefits, a claimant’s net income cannot exceed 80 to 85% of their pre-disability net income.
The benefits are tax-free if you paid all or part of your premiums with after-tax dollars. This is usually the case with individual disability plans.
If your employer pays part or all of your employment benefits package premium, your disability benefits will be subject to income taxes. However, the benefit might be non-taxable in certain circumstances, provided the premium amount is treated as a taxable benefit to the employee and reported on a T-4 tax information slip.
If you are not represented by a lawyer, then yes, you should. Often, disability carriers need permission to obtain clinical information from your first-party providers to help them assess your claim better. When you sign an authorization, you are giving your disability carrier permission to obtain your health-related information from your treatment providers, your plan sponsor, hospitals, rehabilitation clinics, etc. If our law firm represents you, then your disability carrier should not be sending you correspondence or speaking with you.
The cost-of-living adjustment, otherwise known in most policies as COLA, provides for a regular monthly income benefit coverage based on a formula that reflects cost-of-living increases.
If you qualify for disability benefits and then try to return 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 disabled for six months, she receives long-term disability benefits after her elimination period and eventually tries to return to work. After several months, she suffers another heart attack that leaves her 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 before and after the change in definition.
Typically, your benefits will end once you reach age 65, although you should check your booklet or speak to your HR manager. Policies vary from insurance company to insurance company.
The frequency of requested clinical records is up to your individual claims adjuster. However, if you suffer a total disability that prevents you from working in any occupation for which is reasonably suited by education, training and experience (i.e. after two years), most disability insurance companies will request updated medical records approximately once every 12 months.
Absolutely. it happens every day. Often, 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 set out in your policy, you are sent to prison, you’re absent from Canada, you do not provide enough medical documentation, you do not apply for CPP, your adjuster has surveillance on you that is inconsistent with your impairments, or, near the two-year mark because your adjuster does not believe that you are unable to perform any occupation. However, adjusters think “it’s time” to cut you off most of the time.
If your insurance company refuses to pay your disability claim or cuts off your monthly benefits because they “decide” you can return to work, you have the right to internal appeals. Typically, internal appeals will require you to submit additional medical documentation to prove your entitlement to disability benefits. Frequently, 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 to contact a disability lawyer after receiving your original denial letter. We always recommend that you start the disability claims process with a lawyer rather than appeal your claim with your insurance company internally (that being said, specific policies mandate that you go through the appeals process first).
When you retain our Ontario disability lawyers, we will obtain all your clinical documentation as far back as possible, usually 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, that information must be appropriately presented to your insurance company. It’s tough for a claimant to order every clinical record independently, and it’s 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, indicating whether you are totally disabled as per your own occupation or any occupation as provided for in your policy. The process is complex and challenging, and experienced disability lawyers should undertake on your behalf.
It’s important to understand that if you have 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 have been denied or cut off your disability benefits, you must retain a disability lawyer with experience in disability law who focuses nearly or exclusively on disability insurance cases.
Please don’t hesitate to call us no matter where you are in Ontario at 1-844-LALANDE or local in the Southern Ontario region at 905-333-8888. Alternatively, you can send us a confidential email through our website – and we’ll set up a meeting to explain your long-term disability rights and legal options at no cost.
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I was a dental hygienist that suffers from really bad scoliosis. My insurance company ignored my doc & cut my benefits off & told me I could do “something”. Matt got me CPP Disability and and LTD settlement – I don’t know what I would have done without him.
My daughter was killed by a drunk driver and it forever changed all of our lives. It seemed that for two years time stopped. This was no an easy journey. Matt let me sit in on the discovery of the driver and boy, he never let up. In the end, our grand-daughter was taken care of and we were compensated for our loss – which we then donated to a cause we believed in.
I call Matt my knight in shining armour. After I was struck by a car while cycling and permanently crippled, he fielded all communications with my especially difficult and downright nasty insurance adjuster. Every step of my care was a battle and I did not have the strength to fight alone.
I lost my leg in a terrible motorcycle accident and Matt help me recover compensation I need because I could not work and the cost of prosthetics and rehab are out of this world. I don’t know what I would have done without him.
My brother ended up paralyzed after a car accident and Lalande did SO MUCH to help get things straight from him getting out of the hospital to all his care for life. We are so grateful for Matt & Heather. I don’t know how my family could have done this without them.
