The lawyers at Aaron Waxman & Associates are experienced with Disability, Personal Injury and Employment claims.
This is part 5 of our long-term disability (LTD) series, where we are looking at various aspects of LTD claims.
Many insurance policies are drafted with very technical terms and unfamiliar jargon that insurance companies repeatedly use in their letters when they deny and terminate claims.
We understand how difficult it can be to receive a letter that says your application for long-term disability benefits is denied or your long-term disability benefits are being terminated when you are in a challenging financial situation. When you don’t understand what some of the terms mean in the denial letter it makes the situation that much more stressful.
One of the many ways a disability lawyer can help you is by explaining what all the terms mean in the denial letter you receive from your insurance company.
Here are some commonly used terms that are important to understand:
#1 - Definitions of Disability (“Totally Disabled”)
In a long-term disability claim, there are 2 definitions of disability (2 “tests”) used to determine if you qualify for disability benefits. First you are assessed as to whether or not you can perform the essential duties of a) your own occupation and then you are assessed to see if you can perform the duties of any occupation. In most policies, the own occupation period lasts for 2 years, but it can be less or more, depending on the policy. It is important to read your own policy to find out what tests are applicable and when they apply.
#2 - Qualifying Period
A qualifying period (also known as a waiting period or elimination period) is the amount of time you must wait between the onset of disability and the first day you become eligible for long-term disability benefits. Qualifying periods for long-term disability policies range from policy to policy.
#3 - Change of Definition
The change of definition occurs when the own occupation period ends, and the any occupation period begins. The definition of disability changes from own occupation to the stricter test of any occupation.
#4 - Appropriate or Reasonable Treatment
You must be under the care of a physician and receiving treatment as part of your disability claim. The treatment you receive should be appropriate and relate to your condition e.g. if you make a claim for a psychological illness, an appropriate type of treatment would be that you are under the care of a psychiatrist and psychologist and taking medications.
#5 - Restrictions and Limitations
A restriction refers to an activity that your doctor has advised you against performing because of the risk of it aggravating your symptoms/risk of harm. A limitation refers to an activity that you cannot perform due to a lack of physical or psychological capacity. A restriction or limitation can be temporary or permanent.
#6 - Functional Limitations
These are restrictions in performing fundamental physical and mental actions of daily life. For example:
#7 - Work Hardening Program
Your insurer may arrange a work hardening program for you if it is felt that you would benefit from a rehabilitation program in order to prepare you for a return to work. This is usually arranged with the help of a rehabilitation specialist that has been assigned to your claim. A work hardening program can be for chronic pain conditions or psychological conditions and usually involve a multidisciplinary approach which can involve treatments such as physiotherapy, kinesiology, chronic pain education, occupational therapy and cognitive behavioural therapy sessions. If the program makes your symptoms worse or you are unable to participate, you must have medical evidence to show why you are unable to participate/continue participating.
#8 - Graduated Return to Work Program
A graduated (or gradual) return to work program is a schedule arranged by your insurer and employer (with the help of a rehabilitation specialist) that gradually increases the number of hours and days you work until you reach full time hours and days at work. Typically, the rehabilitation specialist or insurer will request medical clearance before initiating the program. If you are unable to participate in this program (or continue participating in the program), you must have medical evidence that shows that your symptoms would be made worse by participating.
#9 - Recurrent Clause
Many long-term disability policies have a “recurrence” clause, which means that if you return to work but are unable to continue working as a result of the same disability, you will not have to submit a new application and can make what is called a ‘recurrent’ claim. Under some policies, the time limit to make a claim for recurrent disability is 6 months. It is important to check your policy to find out what the time limit for making a recurrent claim is.
#10 - Offset
An offset is another source of income that you are receiving/entitled to (e.g. CPP Disability Benefits) that your insurer can use to reduce benefits payable under the LTD plan (therefore affecting your monthly LTD payment amount). You should review your policy to determine what other sources of income are offsets under your policy.
#11 - Gainful Employment
The gainful employment test relates to the any occupation period. In general terms, a gainful occupation is one that is able to provide you with, for example, 60% of your pre-disability income. The insurer looks at your education and employment history and tries to determine if you are reasonably able to perform a job that would pay you that amount of your pre-disability earnings.
It is important to hire a lawyer who can clearly explain what these terms mean, in language you understand.
If you or someone you know has applied for long-term disability benefits and been denied, or were receiving long-term disability benefits and your benefits have been terminated, don’t hesitate to contact the lawyers at Aaron Waxman and Associates. We have helped many clients whose long-term disability benefits have been denied and offer a free, no obligation initial consultation with a licensed lawyer which can be scheduled at a date and time that is convenient for you.
* This blog is for informational purposes only and is not meant to substitute legal advice. Please read our disclaimer for further information.
* All of our lawyers are licensed by The Law Society of Upper Canada
* Office in Toronto and able to represent people in the province of Ontario