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When you receive an acceptance letter from your insurance company, the sense of relief is great. You will now have some time to focus on your health and treatment. It is important to understand your obligations while you are receiving long term disability benefits and to know what the insurer will require you to do to continue to receive monthly payments.
Whether your disability insurance plan is offered through group coverage arranged by your employer or under your own private disability insurance policy, you will receive benefits only as long as you continue to satisfy the policy definition of disability. Your claims adjudicator is required to assess your disability claim on an ongoing basis by obtaining regular updates on your condition and treatment and updated medical records. If you can return to work, the assessor is required to terminate your claim.
Your disability income is essential when you are unable to work due to a mental health issue or a physical illness or injury. That’s why it is important to understand what the disability plans require to continue payment. Your obligations while receiving disability benefits can involve communication such as providing medical information and more active obligations such as rehabilitation and attending medical assessments.
When you submitted your disability benefit claim, you completed a claim form describing your symptoms and the restrictions and limitations which prevented you from performing the essential duties of your own job. Your doctor filled out an attending physician’s statement providing medical support for your total disability. This information was accurate when your disability began but it is likely that you have had ongoing investigations, participate in treatment and trial various medications depending on your disability. Recognizing the insurer’s need for ongoing information regarding your claim and proactively updating the insurer each time you have an update or change is a good way to foster a good relationship with your insurer.
There are times when it is difficult to comply with the insurer’s requests for medical evidence such as:
If you are facing one of these issues, it is possible that your insurer will refuse to pay further disability benefits until the medical evidence is provided. Make sure that you document the problem by sending an email or message to your insurer. Call your doctor’s office and report to the insurer about your efforts to obtain the information. If the cost is too great to obtain the report, ask the insurance company to pay your doctor and request the updated medical evidence directly. If the insurer terminates your claim for failing to provide medical evidence, seek legal advice from an experienced LTD lawyer. You can also appeal the insurer’s decision and cite your efforts to obtain the requested information.
If the insurer has not received an update from you recently, they will generally request a progress report. It’s also common for the insurer to require you to complete a questionnaire at regular intervals while you are receiving disability benefit payments such as every 3 to 6 months.
Common pitfalls include:
These questionnaires are often used by insurers to assess whether your statements about your level of disability are consistent with what you tell your doctors, what surveillance shows and what your social media posts say. It’s best to be consistent and to not overstate your symptoms or limitations. If you are earning income and have said you are not, you could lose access to your disability insurance coverage – a most valuable asset.
Most disability insurance plans provide that the insurer can require you to attend a medical examination. The insurer will provide you with the date and location for the assessment. If you are not able to attend the assessment because the date conflicts with an important event or appointment, let the insurer know right away. Cooperate with the insurer’s efforts to schedule the examination. If the examination requires you to travel, it is reasonable for you to ask the insurer to arrange transportation for you or to reimburse you for any expense to attend the appointment.
Your insurance company may set up a Functional Ability Evaluation (FAE) or a Functional Capacity Examination (FCE) to measure your physical capacity to perform certain tasks. It is likely that the company has a right to require you to attend such an evaluation but you should discuss the evaluation with your treatment providers. Your physician may be able to indicate that you should not attend the evaluation or provide parameters for your participation in an assessment.
A FAE/FCE may be useful in determining the lifting restrictions or standing limitations which are imposed by a physical disability. However, these examinations are far less useful in determining whether a person is unable to work due to chronic fatigue syndrome, chronic pain, multiple sclerosis or neurological disorders. These examinations measure whether you can perform certain tasks but they cannot measure your experience of pain at the time or the impact of the assessment on you in the days following the appointment. Therefore, while it is important for you to attend such evaluations, you should be clear when you are in pain or experiencing additional or worsening symptoms during the assessment.
LTD policies allow the insurance provider to require you to participate in treatment that is appropriate for your disability. For example, disability carriers will often provide psychological treatment where disability claimants suffer from mental health conditions. If you have a physical disability, the insurer may arrange for physiotherapy treatment.
Some things to keep in mind when the insurer offers your rehabilitation:
If you require treatment but the insurer has not offered to pay for it, you cannot require them to offer you rehabilitation. However, it is a good idea to document your request (or better yet, your doctor’s recommendation) as you may be able to get the treatment paid for.
While disability benefits provide valuable financial assistance in replacing some of your pre-disability income, everyone wants to work if they can. If you have been unable to work for an extended period of time, most treatment providers will recommend a slow return to the workplace. A graduated return to work can be suggested by the insurer when they see that your condition has improved or your doctor may recommend it.
Some things to consider in participating in a graduated return to work:
You should work with your doctor to determine whether you will be able to return to your own job or whether you need to look at whether you can perform an alternate occupation. Group insurance disability coverage usually provides that the definition of disability changes after the initial period of disability benefits have been paid. If it is clear that you can no longer perform your own job, the insurer may provide you with vocational rehabilitation or vocational assistance.
Vocational assistance may include:
If the insurer offers vocational assistance, you should take advantage of it as long as your doctor is supportive of you doing so. It shows cooperation with the insurer and that you are willing to return to work if you can.
Most group insurance disability policies require you to apply for CPP disability benefits. Group insurance policies usually have an offset or benefit reduction for any disability benefits payable under the Canada Pension Plan. If you do not apply for the benefits when the insurer asks you to do so, the insurer can reduce your monthly payments by an amount that they estimate you would receive. The policy allows them to take this step. There are many other reasons that you should apply for CPP disability benefits such as the fact that if you are approved, it will protect the value of your retirement benefits under the Canada Pension Plan.
The terms of your group insurance LTD policy or private insurance plan provide your insurance provider with contractual rights many of which are set out above. However, if your insurance company has terminated your claim for benefits or you have been denied disability benefits, you should seek assistance from an experienced disability lawyer. Participating in an IME after receiving a denial letter may result in the insurer accepting your claim; however, it depends on your claim and your circumstances. It may be a better choice to sue the insurer and dispute their denial.
If you or your doctor believe that the insurer’s preferred treatment or rehabilitation is interfering with your recovery or causing you harm, get advice about your disability coverage. Our lawyers will provide you with a free consultation to review your situation and the insurer’s demands.
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