Claiming group disability benefits
How does the group disability claim process work?
Employers buy group benefit plans from insurance companies to provide disability benefits to employees. The insurance company is the "benefit provider." Group disability insurance plans are designed to give you some income while you are unable to work due to injury or illness. The term "benefit" refers to money paid out by the benefit provider to an employee who is considered to be disabled and who qualifies for benefits under the plan. The amount is based on a percentage of the employee's income. Eligibility for benefits is based on the terms of your group benefit plan. To apply for benefits, you will make a claim.
Information on eligibility is usually explained in a booklet written by the benefit provider, that you can get through your human resources department or your manager. It is important to remember that the details of group plans vary. You should refer to the benefit plan booklet for details about your coverage.
Who can help me through the claim process?
The disability claim process can sometimes be difficult, especially when your life is disrupted by injury or illness.
Some people who may be able to help you navigate the process include:
- your manager
- human resources representative, benefit plan coordinator
- union representative
- occupational health nurse
- family doctor
- the benefit provider's claim examiner
- rehabilitation consultant
- friend or family member
What are the first steps in applying for disability benefits?
Contact your manager, union representative or benefit plan co-coordinator (this person is often someone in your human resources department) to request information on your coverage and the necessary forms to complete. Often there will be three forms to be completed: one by you, one by your doctor, and one by your employer.
How is the claim decision made? How long will it take?
All completed forms are sent to the claim examiner who then assesses if you are eligible for benefits under the plan.
Typically, to qualify for short term disability benefits, you must be considered unable to perform the duties of your own occupation because of illness or injury.
Typically, to qualify for long term disability benefits, in the first two years you must be considered unable to perform the duties of your own occupation because of illness or injury. Typically, to qualify for benefits beyond the two-year mark, you must be considered unable to perform the duties of any occupation, because of illness or injury, for which you may have training, education or experience.
The claim examiner may ask you for additional information after you have submitted the forms. The claim examiner may need further details about your situation, or more information from your doctor. Often the claim examiner will phone you to collect or request this information. Claim decisions can take from one week to several weeks.
To reduce delays in the claim process:
- Call your claim examiner to ask questions about the status of your claim and what you can do to move the process along.
- Send requested documents by fax and ask your doctor to do the same.
When will I get paid, how much, how often and for how long?
Short term disability benefits are usually paid every one or two weeks.
Long term disability benefits are usually paid monthly.
Benefit amounts are typically calculated as a percentage of your regular income. The percentage amount depends on your benefit plan. Benefits will continue as long as you continue to meet the definition of disability set out in the group benefit plan, or if you reach the maximum benefit period as specified in the plan.
What can I expect if my claim is approved?
If your claim is approved you can generally expect your claim examiner to request periodic medical updates and assess your readiness for return to work.
An independent medical examination (IME) may be arranged for you if the claim examiner wants a second medical opinion to provide clarification of your diagnosis and functional abilities. The independent medical examination (IME) may also make recommendations for treatment and return to work planning. A copy of the IME report is usually sent to your doctor who can review any recommendations with you.
In some circumstances, your case may be referred to a rehabilitation consultant who may meet with you to discuss recovery and return-to-work planning
The rehabilitation consultant may help the people involved in your claim communicate with each other, including your medical treatment providers and your employer. The rehabilitation consultant can help with return-to-work planning and by providing support and guidance during the return-to-work process.
What will my employer be told?
Privacy regulations protect your private medical information. Benefit providers are restricted from sharing your personal and medical information with your employer.
The claim examiner may share information about your limitations and restrictions with your employer to help with return-to-work planning.
What if I'm not 100 per cent well when I return to work? What if I get sick again?
When you return to work after a period of disability, it is often recommended to do it gradually, depending on your situation. Getting back to work may help you in your recovery. The return to work usually starts when you are sufficiently recovered to participate in some work activity. Ongoing recovery may take place as you return to work. Commonly, hours and duties are modified for a period of time to allow employees to transition back to work safely and successfully. Feeling productive at work and re-connecting with co-workers often contribute greatly to recovery.
If your condition worsens following your return to work, you may again be eligible for disability benefits. Your claim may be reopened if your disability is considered a recurrence (as defined in the benefit plan) or you may have to submit a new claim.
What if my claim is denied or my benefits are terminated?
Claim denial or termination is usually a result of not meeting the definition of disability as set out in the group benefit plan. If your claim is denied or terminated, you would usually hear from the insurance company by letter.
If you do not understand the reasons your claim is denied or terminated:
- Contact your claim examiner to ask for an explanation.
- Ask about your options and next steps.
- Ask your claim examiner if there is an appeal process and, if so, what additional information may be required to proceed.
- Request that reasons and next steps be sent to you in writing.
- Review the information received with your doctor or someone who can help you take the next steps.
- You may want to ask your employer about any other options including a modified return to work, severance, early retirement, and other benefit entitlement such as employment insurance.
If you are not satisfied with the answers from the benefit provider, you may be able to use the benefit provider's complaint resolution process. If you continue to not be satisfied, you may wish to seek legal advice although it is not usually necessary to hire a lawyer to communicate with the benefit provider about termination of benefits.
You may also contact the Canadian Life and Health OmbudService, a national health insurance dispute resolution system for consumers, found at http://www.olhi.ca.