The lawyers at Aaron Waxman & Associates are experienced with Disability, Personal Injury and Employment claims.
This is the second of two blogs posts that will explain some commonly used terms in long-term disability insurance policies and denial letters. As we discussed in our last post, many insurance policies are drafted with confusing and technical terms that appear in denial letters. This is why it is important to hire a lawyer who practices disability law and can help you understand the meaning of these terms and why your claim was denied, and of course, represent your best interests.
Here are some further commonly used terms that are important to have an understanding of:
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.
Functional Limitations: These are restrictions in performing fundamental physical and mental actions of daily life. For example:
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.
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.
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.
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 considered to be offsets under your policy.
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.
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, 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