By Matt Lalande in Long-Term Disability on January 10, 2022
There’s no doubt that unexpected illness, injury or disability can be financially devastating. Luckily, many employers, as part of their health benefits package, offer employees the option of purchasing long-term disability benefits – which are financial benefits which provide financial assistance in the event that an illness or injury prevents you from working.
The benefits, if one qualifies, provides for a monthly payment of a portion of your income, normally in the range of 60% to 65%. The monthly premiums are set by insurance brokers/insurance companies after market, as part of your group benefit plan, and normally paid partially or fully by the employer or employee. Underwriting (i.e. when the insurance company evaluates and assumes risk) is normally done at the time that you apply for long term disability benefits since individual employee medical histories are never required by employees at the time the group benefits were put into place. You can read more about RBC Group Long-Term Disability Benefit Coverage here.
Disability insurance might seem like a great employment “perk” or a great trade-off, as you pay a premium today, and the disability insurance company agrees to pay out benefits to you in a time of need. The problem, however, is that many disability companies, such as RBC Insurance, often wrongfully deny valid disability claims, leaving their insured financially destitute in a time when they need help the most.
RBC long term disability insurance is like most other types of long-term disability insurance offered by Canadian insurance carriers. From a group benefits standpoint, most employers offer long-term disability coverage as a benefit through their health care plan or pursuant to their collective agreement. LTD premiums are often much lower then the cost of premiums when purchasing an individual disability policy.
Long-term disability provides a percentage of an employee’s monthly income if that employee is considered totally disabled as per policy definition. The maximum duration of an RBC long-term disability insurance is usually to age 65 and the most common elimination period is three months. During the elimination period, the employee would either collect EI sickness benefits or short-term disability.
RBC disability policies normally state that employees would qualify for long term disability benefits when considered “totally disabled”. The definition of totally disabled often varies from insurance policy to insurance policy however in most cases, the definition of “totally disabled” during the first two years of disability means that an employee is unable to perform these substantial duties of his or her own job, often referred to as the “OWN OCC”.
After two years of benefits, a separate definition of total disability is triggered. In most cases, the second definition is referred to as the “ANY OCC” definition, meaning that a claimant is unable to perform the substantial duties of any occupation for which he or she is reasonably suited by education training or experience.
To apply for RBC long-term disability benefits, you must:
Once you submit your application for long-term disability benefits, an adjuster will be assigned to work on your case. Your adjuster (also called a disability claims adjudicator) has the right to order your medical records if you signed health authorizations at the time you applied for long-term disability benefits. In most, if not all cases, disability insurance adjusters will request medical records from your family doctor. Most of the time, and in the general course of things, your family doctor’s clinical notes and records will contain clinical injuries and summaries of visits, prescription summaries, internal notes, summaries of contact with you, referrals to other specialists, as well as the medical records from other providers you have seen such as hospitals, walk in clinics and specialists.
In addition to requesting medical records, there will be an interview with you, which most of the time is done by phone. The interview will seem more like a conversation or a question and answer period. The adjuster will ask you questions about your sickness, illness or injury, as well as your employment and general life. Most of the time the adjuster already knows the answers to questions if he or she is in receipt of medical documentation and has reviewed your social media profiles. They also most likely ask you about a typical day, your symptoms, medications you’re taking, a summary of your treating physicians, your last and next medical appointments, and whether or not your condition has worsened stabilized, or stayed the same.
Remember, when you apply for long-term disability benefits, the onus is on you to prove that you are totally disabled from your own occupation. In most cases, it does not matter if you can complete menial tasks or the functions of other jobs, you must be substantially unable to do the duties of your own job.
Your RBC disability claims adjuster will then review his or her interview notes, any subsequent clinical documentation received and then decide whether or not you meet the definition of total disability as set out in your long-term disability contract.
Unfortunately, at this stage, RBC like many other long-term disability insurance companies, routinely and wrongly deny long-term disability benefits. If this happens, RBC will encourage you to file what is called “an internal appeal”. Unfortunately, in our experience, filing an internal appeal simply delays the disability claims process further.
The RBC internal appeals committee, which is in most circumstances, and other adjuster, will then request you to provide further documentation for their review. The further documentation can be in the form of a letter from you, letter from your doctors, further medical records, specialist records or anything that you wish your disability claims adjuster to review in support of your appeal. In our experience, the internal appeals process rarely overturns an initial long-term disability claim denial. Rather than filing an internal appeal, you should hire a long-term disability lawyer immediately. The longer you wait to hire disability lawyer, the longer you will wait to get paid.
Some of the reasons why RBC might deny long-term disability claims are as follows:
You do not meet the definition of total disability – in most circumstances, your long-term disability adjuster will come to the conclusion that he or she believes that you could perform the substantial duties of your job. In other words, your disability claims adjuster may, based on the evidence provided, come to the conclusion that your injury or illness is not significant or severe enough to interfere with you performing the substantial duties of your own occupation and refuse to pay your monthly disability income.
The problem is that many disability claims adjusters fail to properly interpret their own policies correctly and wrongfully deny long-term disability benefits to claimants who properly deserve them. We have often seen adjusters state to claimants that they can either do less work, work part-time, or work a similar job when in fact most policies are more than clear that claimants are entitled to long-term disability benefits if you cannot complete the substantial duties of your own employment. The contractual elements that RBC insurance and your employer agreed to, initially, when your benefit plan was put into place, must be adhered to.
You adjuster may not have sufficient medical evidence: – if there is insufficient evidence provided to RBC disability insurance, the insurance company simply might not have enough to work with in order to come to a decision. Remember, the onus is on you as a disability claimant to prove that you are disabled pursuant to your disability policy. The disability carrier is not considered an investigator by law. Our courts have said that disability insurance companies only need to go so far when investigating and adjudicating the disability claim. We always advise that, no matter what, you provide as much medical documentation as you can to your long-term disability claims adjuster. The problem with this however, is that many people who are sick or hurt – and not receiving an income – lack the funds to be able to obtain the medical documentation from hospitals, doctors and specialists. All of this cost money – and the disability carriers well aware of this.
Information can be missing – there can also be missing information at the time of your application. For example, your family doctor may have not submitted your attending physician statement, your employer might not be cooperating or your clinical providers might have submitted insufficient medical documentation. It’s important for you to speak with your disability claims adjuster on a regular basis to ensure that all of your application materials have been submitted for review. keep calling, keep emailing.
Failure to adhere to a recommended treatment plan – many disability benefits applications are denied based on the fact that claimants are not adhering to a proper recommended treatment plan. Throughout the past several years however COVID has terribly interfered with the ability of a person to obtain in-person treatment. In other cases, treatment is simply not accessible. Over 80% of long-term disability claims are mental health claims and if a person is a suffering from major depressive disorder, bipolar disorder, anxiety etc. it’s not always easy to get appropriate and consistent treatment besides visiting one’s family doctor, taking the appropriate and recommended medication. Also, if a person cannot continue paying the premiums on his or her group healthcare plan while he or she is disabled, then access to therapy will be cut-off. In most cases, it simply not possible for a person to pay out-of-pocket for treatment that is not covered by OHIP. For many people, the focus is simply an paying the mortgage or rent and surviving.
Has RBC denied your long-term disability benefits at the two-year mark?
RBC Insurance disability policies, like most other Canadian disability insurance companies, changes the definition of what “total disability” means a person has been on disability for two years . The change, often known as the “change of definition” or “COD” for short happens after two years. RBC disability insurance policies provided that total disability within the first 24 months of benefit payments as established where a person is unable to perform the important duties of his or her own job, even though the person may be capable of performing another occupation. After 24 months of disability payments, RBC disability insurance policies typically switch from an “own occupation” definition to an “any occupation” definition of disability, which means that the person must be unable to perform the activities of any occupation for which he or she is reasonably suited by reason of his or her education training or experience.
Understandably, it is at this intersection that many disability insurance companies tend re-assess most, if not all of their open and active disability claims. One must be able to prove at this junction that because of his or her medical condition, he or she is prevented from engaging in any occupation for compensation or profit. An alternative occupation must be something that is comparable to the insured’s former line of work in status and potential earnings. Even if the policy doesn’t contain the words “reasonably fitted by education, training or experience,” the proposed occupation must be something for which the insured is qualified by virtue of his schooling and work experience.
The problem that we see time and time again – is that many disability claims adjusters seem to focus on pushing claimants into a return to work (RTW) without proper assessment or a proper understanding of the claimant’s medical condition. Vocational specialists or rehab workers are often retained by RBC Insurance to help the claimants in their RTW – no matter if the claimant or their doctors thinks that they are ready.
Being denied your long-term disability benefits is not the end of the road. You will have the right to an internal appeal – but more importantly, you have the absolute right to hire a disability lawyer to protect your legal rights and to help get your long-term disability benefits back on track.
If you’ve been denied long-term disability benefits it’s important that you retain a disability lawyer with experience. Our disability lawyers have been representing claimants denied their long-term disability benefits since 2003. We NEVER charge consultation fees and we only get paid IF you get paid, at the conclusion of your case.
If RBC Insurance has denied your long-term disability benefits, call us today, no matter where you are in Ontario at 1-844-LALANDE or local in the Burlington/Hamilton/Niagara areas at 905-333-8888. Alternatively, you can send us an email through our website and someone from our office will get right back to you to schedule an appointment to talk about your long-term disability issue.