Over the past 20 years our disability lawyers have seen time and time again that claimants who are denied short-term disability benefits will more likely than not suffer terrible financial hardship. Then, the emotional distress from the financial burden that is created when claimants are denied short-term disability benefits often has a cumulative impact that often leads to larger problems.
Remember, if your employer offers short-term disability benefits through your group benefits – you have the full right to apply for disability monthly benefits if you are substantially unable to complete the duties of your OWN employment. The contractual test that is set out in your group policy (which most claimants are unaware of) is not a very onerous one. The problem is that disability insurance companies often do not properly consider or seek to understand a claimant’s disability – either it being psychological, emotional, cognitive, or physical, and take it upon themselves to weigh the medical evidence as if they themselves have a medical background or training.
While it is true that adjusters make decisions based on what medical evidence is provided – often times the decision to deny short-term disability benefits is made because the adjuster simply “thinks” that you can work or complete the tasks of your own job.
The reality is for a claimant that suffers a disability there is always more. There is more of a history, or a story. There is often a long-standing psychological or emotional issue that comes to a head – or a breaking point. There can also be a chronic physical ailment which a person has been suffering from, that flares up – either due to an accident, age or the body simply giving out. There could be a history of mental health issues that a claimant has been suffering from an abusive childhood that has finally reached a breaking point. In our experience as disability lawyers in Ontario, there is more to what the disability insurance company knows or understand….or cares to know and understand.
We understand that a denial of disability benefits can cause emotional aggravation and frustration. We understand that being sick or hurt, then to only be denied short-term disability benefits can devastating. If you have been denied short-term disability benefits, we understand that you might think it is some kind of bureaucratic error – but we urge you to not contact your disability insurance company in an emotional state. It is vital that you contact a short-term disability focus on your injustice and get things on track for you.
In Ontario, short-term disability benefits are normally available if you are unable to complete the substantial duties of your own employment.
It depends on your disability policy, but typically in most cases, short-term disability lasts for 120 days.
You normally qualify for short-term disability if you can prove that you are unable to complete the substantial duties of your employment because of an illness, chronic disease or injury.
It depends. Some employers who offer short-term disability do not offer long-term disability. In these types of cases the claimant must first apply for EI Sickness benefits before applying for long-term disability.
If you applying for short-term disability as part of your employment benefits, you would speak to you benefits administrator. If you are applying as part of an individually purchased disability policy, you would speak to your broker or directly with your insurance company.
It depends on your policy. Typical policies pay short-term disability benefits 65% of a person’s salary. In some cases with municipal, education or unionized employees, the percentage can be up to 70%.
They cannot terminate you because you are disabled, but employers in Ontario can terminated anyone so long as the appropriate reasonable notice it paid.
if your short term disability claim was denied, call our Ontario disability lawyers at 1-844-525-2633 or at 905-333-8888 and we will be happy to walk you through your options as a policy holder and what your legal rights are.
We cannot answer for other firms or lawyers, but talking with our Ontario short-term disability experts is 100% free AND if we decide to work together, we will never charge you upfront fees.
In order to understand short-term disability benefits it is important that you understand the different types of disability benefits available to a person if he or she suffers a chronic illness, disease, disorder or injury which prevents you from being able to work.
Firstly, there are government plans which provide disability benefits such as the Canadian pension plan (CPP), the Québec pension plan, unemployment insurance and workers compensation (WSIB) plans. These plans offer very limited financial protection as part of Canada’s Social Security benefits.
Secondly, disability benefits can be offered through group benefit plans offered by your employer or association. These types of benefits generally offer more limited protection, but at a lower cost to the insured (or the employer). This is referred to as private insurance.
Thirdly, disability benefits can be provided by an individual policy that is purchased directly from an insurance company on a client by client basis. Individual disability policies often offer the most extensive protection, but at a higher premium cost to the insured. This is also considered private insurance.
Short-term disability benefits are a type of private insurance which pays you a portion of your income if you are unable to work due to an injury or illness. Short-term disability is typically offered as a part of employment group benefits. Not all employers in Ontario offer and there is no legal requirement to offer short-term disability benefits. Your employer might not offer short-term disability, which means that you either need to paid or unpaid leave. If your leave is unpaid, then you may want to apply for EI sickness benefits. Remember, before you can start receiving EI benefits there is a one-week waiting period in which you will not be paid.
Typically you would talk to your benefits administrator or your HR department and obtain a short-term disability application package. Most short-term disability packages will contain a plan member statement, a plan sponsor statement and an attending physician statement. You must fill these documents in accurately, and provide the attending physician statement to either your family practitioner or whatever specialist that you are seeing in regards to your current medical condition.
The plan member statement or short term disability claim form will be an online or .pdf questionnaire asking about your condition, how it occurred, your overall medical history and any expected income while you are on short-term disability. The plan member statement will most likely include a direction or authorization which allows the insurance company to communicate with and obtain clinical documentation from your doctor concerning your health and disability.
Your plan member statement or short term disability claim form will ask for such things as:
The attending physician statement will be signed by your doctor and provide a diagnosis and prognosis of your overall condition. All clinical findings should be included on or within the statement. The attending physician statement will also require your doctor to forward any specialist consultation notes. The attending physician statement will outline your particular medical issues, diagnosis and when/if your doctor expects you to return to work. The attending physician statement is a required and standard document with respect to all short-term disability benefits applications.
What you won’t see, is a short-term disability benefits form that is also sent to your employer or plan administrator – which is typically to get more information about your employment, your disability, your time away and your income in order to calculate your monthly short-term disability benefit payment. The form is similar to your plan member statement or short-term disability claim form, but it’s meant for your employer or plan administrator to fill out. The form will typically ask for such things as
You will qualify for short-term disability benefits if you meet the definition of total disability within the context of your particular insurance policy. Take a look at your disability benefits booklet and read the particular provision or definition regarding total disability and what that means in relation to your injury or illness.
If you are eligible to apply for short-term disability benefits, there may be a waiting period or a qualifying period or your short-term disability benefits may start right away. It depends on your particular plan.
Your disability insurance company will review the medical documentation regarding your injury or illness that you submit to them, as well as your doctors attending physician statement and then determine if you meet the definition of disability as it is defined in disability policy. Your doctor must provide an attending physician statement to your disability insurance company in order for you to qualify for short-term disability benefits.
The disability benefits adjuster assigned to your particular case will more likely than not interview over the phone about your injury or illness once your application for short-term disability benefits has been received. If you are unable to communicate by phone for any reason (e.g. hospitalized) your case adjudicator should make other arrangements to communicate with you or your power of attorney to discuss your claim. Sometimes they may call your doctor to ask additional questions concerning your short-term disability benefits application. Normally it will take a few weeks to process your application for short-term disability insurance. Once your insurance company has made a decision, they will inform both you and your employer of their decision.
Your case manager must not work an adversarial manner with you. Rather, the case manager must provide a reliable and timely decision on your claim as to whether or not you meet the definition of total disability. That case manager must also provide clear and concise and reliable answers to any questions that you may have about your claim.
After all the required information has been gathered, your case manager will review your claim to determine your eligibility for benefits based on your group benefits contract. If your claim is approved, you will probably receive a letter from your insurance company advising you of the amount of your monthly benefit and the expected duration for which your short-term disability claim will be paid. The letter may include your initial or retroactive payment. If you completed the direct deposit authorization on the application form, your short-term disability benefit will be deposited directly into your bank account. You will also be provided with details of what to expect from the ongoing claims process.
Some of the short-term disability conditions that we often see claimants suffering from are:
Your disability insurance company is asking you to sign authorizations so that they can order your non-medical and medical information from your doctors and other medical places that you have attended. When you sign an authorization, you are authorizing and permitting your disability insurance carrier to obtain all of your private information from your doctor, employer, other insurance companies, or from anyone else or wherever else you received treatment.
To better understand, doctors in Ontario have a professional responsibility to protect your confidential medical information as a patient. As a general rule, the only way medical doctors or medical institutions would release patient information, is if they have the written authorization of that particular patient, or the patient’s substitute decision-maker, or if they are in receipt of a court order. By signing authorizations and providing those authorizations to the insurance company, you are giving them full disclosure and full access to your private medical records. It’s best that you speak to a disability lawyer prior to signing any medical authorization.
Your doctor needs to provide a clear diagnosis and prognosis to the insurance company. In addition, most policies mandate that you need to be any treatment program or follow appropriate treatment recommendations by your doctor to promote your overall recovery. It is your doctor’s clinical notes and records that will be provided to the insurance company to help them adjudicate your claim.
It depends. Typically you would receive short-term disability benefits if you satisfy the definition of total disability as per your contract, meaning that you are not able to perform the substantial duties of your own occupation for the maximum benefit period. The maximum benefit is the term chosen by your employer that is defined in your certificate of coverage. In most cases, your STD benefits are payable anywhere from 120 days to 6 months.
Monthly short term disability payments are based on a percentage of your pre-disability income at the time you are approved for LTD. Typically the benefit is a percentage of your weekly earnings that is specified in your individual policy or your employee benefits booklet.
This depends on whether or not you are your employer paid your premiums, or perhaps a mix of both. Benefit taxability is determined on how your premiums or paid. For example, if your employer or employee paid the disability premiums on a pretax basis, then the benefits would be taxable. If you paid for your premiums after taxes, then the benefit would be nontaxable.
If your illness or injury is expected to cause you to remain off of work at the end of your maximum benefit period, then you will need to convert your coverage to long-term disability benefit coverage. Long-term disability will continue to be paid to you so long as you satisfy the definition of total disability as set out in your disability policy. Most long term disability benefits begin about 120 days after the onset disability, but it’s important that you do not wait until the end of the elimination period before filing your disability claim.
Insurance is one of the only products that we ever purchase, either privately or through employer offered benefits, with the hope that we will never have to use it. Many of you have paid years and years of premiums with the expectation that the benefits will be paid when you need them most. That is why it is so disappointing and frustrating when you ultimately file a claim and the insurance company refuses to honor its end of the bargain and denies your application for disability income benefits.
If you are denied benefits, don’t give up! You can more likely than not file an internal appeal. Your insurance company is waiting for you to give up. The disability insurance company wants to wear you down so that you return to work while sick, dying, hurt or abandon your claim completely. We’ve heard this referred to this as “starving out” the claimant. If an internal appeal does not work, or you do not have the option to appeal your short term disability benefits – you have the option of hiring a disability lawyer to represent you and ask a Court to declare you disabled as per your policy definition and pay your benefits.
The reality is however, most people do not know that they have the option of hiring a lawyer after they’ve been denied their short term disability benefits. It is hard enough to deal with the day-to-day limitations due to your medical conditions. It is not surprising, therefore, that most policyholders do not bother with seeing the claim through to the end. The insurance companies know this and that is why they deny so many claims.
Keep in mind that your time to file an appeal or file a lawsuit is limited. Don’t throw away the denial letter and give up. Contact an short-term disability lawyer to assist you in fighting the wrongful denial of your benefits. Remember, our Ontario Short-Term Disability Lawyers have been fighting for the rights of victims for nearly 20 years. If you’ve been denied short-term disability, call us today at 1-844-LALANDE or local at 905-333-8888.
There are certain instances where short-term disability may not be paid – each of which have been individualized in your own disability booklet or policy provided to you by your broker or your employer. In our review of disability policies over the years we have seen such exclusions as:
Yes you need to complete a separate long-term disability application and submit the application to your insurance company. If you do not, you may in fact forfeit your right to benefits. Your insurance company should provide you with your LTD forms prior to the end of your short-term disability and if they don’t, you should make that request. Again, you will be required to submit a members plan statement in attending physician statement. Please review your policy in order to determine how long you have to make the application and transition to long-term disability benefits.
There can be a variety of reasons why your short-term disability claim is denied. Typically, our disability lawyers see much more long-term disability claims denied then short-term disability denials.
Your short-term disability claim denial could have been due to you not submitting enough medical information in order to assess your claim. Also, your doctor or clinical provider may not have taken complete notes or have accurately documented your medical issue or treatment, which can cause confusion to the disability insurance company. Most disability policies mandate that you have to be in and remain in active treatment. If you did not follow your doctor’s advice, or you have not participated in active treatment, then your disability claim can be denied.
Your disability can also be caused by one of your policy exclusions, such as drug and alcohol addiction. If drugs and alcohol are the main factors of your disability, then please review your policy. Substance abuse an addiction is typically excluded from most disability plans.
We understand that being unreasonably denied your short-term disability benefits can be very stressful and frustrating. If you suffer from a chronic condition or serious injury that prevents you from working – and you have been wrongfully denied your short-term disability benefits – call our Hamilton Disability lawyers today no matter where you are in Ontario at 1-844-LALANDE or local in the Hamilton/GTA at 905-333-8888 or send us a confidential email through our website and we would be more than happy to sit and speak with your about your situation, at no cost to you.
Our Hamilton Disability Lawyers have been representing disability claimants at all stages of disability since 2003 and have litigated against some of Canada’s top disability carriers. We can help get your benefits back on track.