The lawyers at Aaron Waxman & Associates are experienced with Disability, Personal Injury and Employment claims.
There are many terms and provisions used in insurance policies that sound confusing and difficult to interpret. When you are on claim (receiving benefits) and receive letters from your insurer, you may see various terms used that you haven’t heard of before, like “total disability”, “own occupation”, “any occupation”, “gradual return to work plan”, “rehabilitation provision” and wonder what they mean and how they apply to you.
This is part 1 of our blog series that will take a closer look at certain terms/phrases used in long-term disability claims. This blog will look at rehabilitation provisions and gradual return to work plans.
When you are initially approved for benefits and receive the approval letter, you are often provided with an overview of your plan’s “definition of disability” (the criteria you must meet in order to be considered disabled under the policy). Group plans typically have 2 definitions, one for own occupation and one for any occupation.
You have been receiving long-term disability benefits for a period of time and your case manager (the insurance adjuster) tells you that a rehabilitation consultant will be assigned to your claim to help you with a gradual return to work.
You may be wondering what this means, what it involves and what your responsibilities as the employee (as the insurer refers to you as) are. You may also be asking if you have to participate in this program.
While you are receiving benefits, your case manager periodically reviews your claim to determine if you continue to meet your policy’s definition of total disability. When considering this criteria, your ability to work is taken into consideration as it relates to your medical condition as well as what the expected recovery time is and if you have received/are receiving appropriate treatment.
If your case manager assigns a rehabilitation consultant to your claim, it seems that your insurer feels it is an appropriate time to offer assistance with returning to either to your own occupation or an alternate occupation depending on how long benefits have been paid for or on the nature of your disability. The test for disability in the any occupation period is stricter and more difficult to meet and the case manager in addition to medical information takes into consideration your level of education, type of training you have received at your occupation and experience.
The rehabilitation consultant’s role is to determine what kind of gradual return to work plan is appropriate and what type of work hardening program or assessments, if appropriate, are necessary before this takes place. This occurs because your insurance company is trying to determine what your restrictions and limitations are.
A gradual return to work plan could be, for example, 4 weeks to 8 weeks, or more. A gradual return to work plan means you return to work on a gradual basis, i.e. the 1st week you work 2 -3 days, maybe every other day, for 4 hours per day and you increase your hours and the number of days you work each week so that by the end of the program you have achieved full time hours and days. Your duties may have to be modified and the rehabilitation consultant is supposed to provide this information to your employer.
How does your insurance company know what your limitations and restrictions are? It is not uncommon for your case manager to write to your treating physician(s) and ask for an update on your current health status and to ask if there are any symptoms or reasons why you are unable to return to work (your own job or any job) at that time or in the near future, and if you are, what your limitations and restrictions would be. If your insurer has requested that you participate in a work hardening program, the case manager will ask that these types of questions be answered in progress reports/discharge reports. It is also possible that an independent medical examination is arranged.
Another way insurance companies try to find out if you are able to work and what your limitations and restrictions are is through what is known as a functional capacity evaluation (FCE). This assessment typically occurs over the course of 2 days and the results of testing are used to determine if you could work a sedentary, light, medium, heavy strength demands type of job.
After your case manager receives this information, if he/she feels that there are no medical contradictions (physical or psychological) preventing you from starting a gradual return to work plan, the rehabilitation consultant is asked to put one in place. You will be advised of this and usually under a rehabilitation provisions, if an employee does not participate or cooperate in a rehabilitation program or plan that has been approved, he/she is no longer entitled to benefits.
What happens if you try working and your symptoms are exacerbated? What do you do? You should advise your doctor(s) of any new or worsening symptoms you are experiencing and advise your case manager and rehabilitation consultant. If you are unable to follow the plan, you will be advised by your case manager that you are responsible for submitting additional information that explains why you cannot continue working.
What if your doctor believes you cannot participate in the plan or it is too soon for you to return to work? The same type of information is required and your insurance company wants you to provide medical evidence that proves your inability to work.
The type of evidence that your insurance company is looking for includes documentation (doctor’s records, specialist’s consultation reports, test results) that supports your symptoms, complications, treatment and other factor that contribute to a longer than expected recovery. If your pre-disability position was sedentary, and your disability is related to chronic pain or psychological illness (an “invisible illness”), it is important to demonstrate how your symptoms impact your function and activities of daily living, i.e. your ability to focus and concentrate, interact with others and the general public.
If you or someone you know have been denied long-term disability benefits, you should contact a disability lawyer to find out what your legal rights and obligations are. Our office offers a free initial consultation with a licensed lawyer that can be arranged 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