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Long Term Disability Benefits & Claims: Your Roadmap

Our office gets a number of calls every week from people wanting to know if they qualify for Long Term Disability (“LTD”) benefits; how they can make a claim; or just how their LTD policy works.

This article in intended to give you a bit of help in better understanding the complicated world of Long Term Disability Benefits.

    LONG TERM DISABILITY BENEFITS: WHAT ARE THEY?

Long term disability benefits are meant to protect an employee or working person from a loss of income in the event they cannot work by reason of injury, illness or disease. Essentially, if you CANNOT work for a prolonged period of time by virture of accident injury, illness or disease; and you have a LTD policy, you may be eligible to claim Long Term Disability Benefits from your LTD provider/insurance company.

NOT EVERY EMPLOYER OFFERS LTD BENEFITS TO THEIR EMPLOYEES. LTD benefits are a perk of employment. Some employers offer LTD benefits to their employees. Others don’t. Check with your employer. If your employer doesn’t offer LTD benefits, you may want to take out your own personal LTD policy with an insurance broker. Most brokers will sell individuals policies of LTD insurance. The nice thing about taking out your own personal LTD policy is that you have the freedom to pick the policy which best suits you; your rate of coverage and the policy will follow you from employer to employer in the event that you change jobs. The other nice thing is that by taking out your own LTD policy is that you don’t have to be subjected to your employer’s LTD policy which might not provide the best level of coverage.

    HOW DO I MAKE A CLAIM FOR LONG TERM DISABILITY BENEFITS?

Every company has a different method to make a claim. With some companies, all you need to do is make a call to the insurer and they will send you some paper work to fill out. Other companies expect you to first speak with your employer about making a claim. Other companies may want you to go on-line. My point is that different companies have difference policies and procedures to make a claim; and they will have different forms to complete as well. The forms they ask that you complete are self-explanatory, but can be difficult if English is not your first language. If you need help, get it. Most, if not all insurance companies will want a doctor to complete a disability certificate so they can substantiate the medical reason for which you are unable to return to work. This is completely normal. If your doctor wants money to complete the form, send their bill to the LTD insurer and they will likely pay for it. Failure to complete all the required forms will result in an incomplete LTD application and may delay or jeopardize your claim. Make sure that you’ve dotted all of your i’s and crossed all of your t’s. Get that paper work in. It’s important to your claim.

    HOW DO YOU QUALIFY FOR LONG TERM DISABILITY BENEFITS?

Every policy of LTD insurance will include a definition of disability. In order to quality for LTD benefits, you will need to meet the policy’s definition of disabilty. Every defininition of disability is different. I’ve seen some attrocious policies which state that an insured person will only meet the definition of disability IF they have lost a limb and they can no longer perform the essential functions of ANY occupation. I’ve seen other definitions of disability which state that you CANNOT be considered disabled by reason of a soft tissue injury, psychological/psychiactric illness, fibromyalgia or chronic pain. The definition of disability all depends on the wording of your policy. The better the policy, the fewer exclusions you will find and the more lenient the definition of disability. The cheaper polices have exclusions for nearly everything under the sun and make it virtually impossible to make a claim, so watch out.

    OWN OCCUPATION VS. ANY OCCUPATION: WHAT’S THE DIFFERENCE?

LTD policies make reference to an insured person’s ability to work at their “own occupation” AND “any occupation“. In some policies, the definition of your ability to work at your “own occupation“, changes to “any occupation” after 2 years.

The better policies stick to the “own occupation” rider. The cheaper policies have the “any occupation” riders.

The following example between Biff and Lance will show you the how both riders work; along with the importance of the “own occupation” rider.

Biff and Lance work at the same nickel mine in Sudbury Ontario. Biff and Lance have to load and unload heavy nickel and nickel minning equipment from carts every day. Their work is highly labour intensive and requires a lot of heavy lifting, bending and prolonged standing. Biff and Lance both sustain the exact same back injuries. They are both no longer able to perform their jobs as nickel miners because their doctors tell them that heavy lifting, bending and prolonged standing is out of the question. Biff and Lance both took out their own policies of LTD insurance, since their nickel mine didn’t offer this benefit. Biff took out a policy with an “any occupation” rider because the premiums were cheaper. But Lance, being the smarter of the two, took out an LTD policy with an “own occupation” rider. Both Biff and Lance made a claim for LTD benefits. Lance’s claim was approved. It was clear to Lance’s LTD insurer that he was completely disabled for carrying on work at his “own occupation“; that being one of a nickel miner. Biff’s application on the other hand was rejected. Biff’s LTD insurer told him that despite the fact that he would be unable to perform his “own occupation” as a coal miner; he would still be able to perform “any occupation“; like that of a telemarketer; work in a toll booth; or work in a call centre. When insurer see an “any occupation” rider, they will try to find ANY job for which you are qualified to work. If you can work at any job; then you won’t qualify for LTD benefits. When Biff heard that his claim was rejected, he was demoralized and regretted taking out the cheaper “any occupation” rider. He also regretted paying premiums for all of those years and ending up with NIL; NADA; ZERO; NOTHING. Poor Biff. He got hurt twice. Now he can’t collect insurance, earn a living, pay his mortgage or feed his family. I think he needs a lawyer….

    WHAT’S THAT WHITE VAN DOING OUTSIDE OF MY HOUSE?

So you’ve made a claim for LTD insurance. You’ve submitted all of the forms, your doctors have performed all of the examinations, and best of all; the insurance company has approved your claim and your monthly LTD cheques are rolling in. But ever since the cheques have been coming in, you’ve noticed a little white van, or a strange looking car parked out on your street with a guy in it who just sits there. He’s there when you wake up in the morning at 9AM. He’s there when you go to the doctor in the afternoon, and he’s there when you eat dinner with your family at night. You also get the strange suspicion that this guy is following you, and taking pictures to boot! If you get that creeping suspicion that there’s a guy tailing you; there may very well be.

I want to share a secret with you. Insurance companies are in the business of MAKING MONEY. Lots and lots of MONEY. They like taking your money in premiums; but hate paying it out in benefits. Because when insurers have to cough up money in paid benefits to you; they aren’t making as much money as they’d like. So, just because an insurance company has approved your claim and is paying you monhtly benefits; doesn’t mean they aren’t still skeptical about the legitimacy of their claim. Insurers hire real life private investigators (like you see on the movies) to follow you to make sure in fact that you are disabled. Take poor Lance the nickel miner from my previous example. Remember how he hurt his back and couldn’t go to work as a nickel miner? He was getting benefits which made his life financially comfortable. One weekend, Lance’s friend Rick invited him to his cottage on the lake. Rick just bought a brand new speed boat for waterskiing. Rick coaxed Lance to waterski. Lance knew that he shouldn’t because his back hurt and his doctor told him not to participate in these sort of activities; but who could resist Rick’s new speed boat? Lance put on the waterskis and went out on the lake. Sure enough, the private eye retained by the insurer took photos and videos of Lance waterskiing on the lake that day. The private eye gave the pics and video to Lance’s insurance company; and guess what; Lance’s benefits were cut off right away because they thought he was a faker. The reasoning was that a guy who’s back pain was allegedly so bad should not be out waterskiing all day long. It’s not my intention to make you paranoid, but don’t put it by an insurer to have a private investigator follow you; or even creep on your Facebook profile to find any dirt they can on you. It happens so beware!

There are many other nuances to dealing with long term disability insurance. This article is just a sampler. If every you need any assistance in making an LTD claim, don’t hestiate to contact Goldfinger Personal Injury Law. One of our lawyers would be pleased to assist you in making your claim and fighting for your rights. It’s what we do and we are proud of it.

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