Group and Individual Disability Insurance
A disability insurance policy that protects against income loss from an accident or disease. There are four basic forms of income replacement: Employment Insurance Benefit (17 weeks); Short Term Disability Benefit (one or two years). STD benefits will be paid if you are "totally unable to perform the duties of your own occupation.". LTD benefits will be paid after the STD period if you are "totally unable to perform the duties of any occupation for which you are or could be suited by reason of training, experience or experience." The Canada Pension Plan (CPP) provides financial coverage for workers who suffer a severe permanent injury that prevents them from working at any occupation. The LTD insurer will reduce your LTD payments by the amount of your CPP disability benefits. Too often disability insurers deny legitimate benefit claims to benefits. If so, experienced insurance lawyer Geoff Aylward can assist you starting with a free initial consultation.
Standard Group Disability Insurance
The standard disability policy is one obtained through work. It generally covers disability only during the period of time the person is working. If you are laid-off you may not be covered.
Short Term Disability (STD) benefits and Long Term Disability (LTD) benefits amounts are paid monthly based on a percentage of your regular basic gross earnings at the time of the injury. (Over-time and bonus pay is not a factor.) The usual percentage is 2/3 your gross earnings up to a particular maximum amount. Provided you have paid the entire premium, the amount of the benefit is non-taxable. For this reason, most employee pay deductions are set up so that the cost of the disability premium is paid by the employee.
Disability insurance applies whether the disease or injury is related to work. You must notify your employer that you are disabled from work and request the forms for disability insurance. Your employer is required to complete one form. Another form must be completed by your doctor. A third form is completed by you. These forms must be submitted within the time period specified in the insurance policy.
The payment of disability insurance usually involves a number of steps or conditions.
- First, sick leave with the employer may have to be exhausted. However, you should still consider applying for LTD if your sick leave is long term, and there is a chance you may not return to active employment.
- Next there is an eligibility period during which LTD benefits are not paid. Generally, sick employment insurance benefits are paid during this period. Under some plans, short-term disability (STD) benefits are paid for up to one year. These short-term disability plans may be funded directly by the employer but administered by the insurer. If there is no STD or after STD expires, if you remain disabled you may be entitled to LTD benefits. LTD benefits are usually both paid and administered by the LTD insurer.
- During the first one or two years, the policy will generally allow benefits if the person meets the test of being totally disabled from performing the duties of his or her own occupation. After the "own occupation period," to continue to qualify for benefits, the person must be unable to perform the duties of "any occupation" for which the person is suited by reason of training, education or experience.
- Disability insurance benefits are generally payable until the person reaches the age of 65 years.
Eligibility for disability insurance does not depend on the availability of employment.
Nearly all disability insurance plans are through employer-sponsored group insurance contracts. A major benefit of these policies is that the premiums are generally quite inexpensive compared to other forms of disability insurance. A major disadvantage is that if the person is not working at the time of the disability, the disability benefits coverage seldom applies. Therefore, there is no coverage where there was a strike, a lock-out, or a seasonal layoff.
Other Types of Disability Insurance & Income Protection
There are a number of other sources where a person may be able to claim disability benefits or income protections. These sources include:
- Individual disability insurance plans are available through insurance brokers. These plans can provide a greater deal of protection and coverage but are generally more expensive.
- Self-employed individuals may obtain the benefits similar to group insurance through professional insurance programs offered through professional or associations.
- Other forms of insurance offer some financial protection if you are unable to work: Creditor Insurance, Critical Illness Insurance, and Automobile Accident benefits B insurance.
- The Public Service Pension Plan and certain other pension plans allow an early retirement benefit if an enrolled member is unable to continue working because of a medical reason. The employee must have sufficient years of employment and meet the medical criteria. The pension is paid at a very reduced rate based on the shorter contribution period.
- During the first 17 weeks that a person is unable to work, if you have sufficient insurable hours, you may be entitled to employment insurance (EI) during that period. Even after that period, you may qualify for regular benefits, provided your doctor can legitimately certify that there is some form of employment that you are able to perform. EI is taxable.
- If you are unable to work as a result of a workplace injury, you will be entitled to compensation under the Workplace Health, Safety and Compensation Act. This Act provides for intensive rehabilitation services, temporary earnings loss (TEL) (when you are being rehabilitated towards maximum level of health). If you are unable to work, you are then placed on extended earnings loss (EEL), which represents the amount that you would be able to earn at the best paying job that exists for someone who has the same level of function that you do. The payment of EEL is lower than TEL. (TEL is intended to represent nearly close to full income loss, subject to a maximum cap.) Worker's compensation is taxable.
- The Canada Pension Plan pays a disability benefit. Eligible claimants must have a sufficient recent period of CPP contribution history. It is necessary that the person be unable to work because of a "severe and prolonged disability." The disability must be for an extended period of time with no immediate prospect of recovery. Usually, CPP disability claims are awarded in cases where the disability is permanent. CPP is a taxable benefit.
Causes of Disability
The right to LTD benefits generally does not depend on the cause of the disability. A hereditary condition, degenerative condition, disease, infection, accident, violent injury or other cause may prevent you from working. The condition may be physical or psychiatric. In some cases, there are limitations that may apply to pre-existing conditions, especially if the pre-existing condition prevents you from working a short period of time after the coverage comes into effect.
You will often not be covered if the disability resulted from an intentional act, such as suicide or even an inherently dangerous act that is tantamount to inviting death.
Denied Disability Benefits
You should make it difficult for your disability insurer to deny your claim. You should obtain and complete the forms thoroughly and promptly and make sure that both your employer and doctor does as well. Your doctor should be aware of the physical and other requirements of your job that prevent you from working. Your employer and co-workers should be aware of the struggles that you have had in the workplace and that you have made every reasonable effort to keep working. It helps if you enjoyed your work and had a long-term commitment to it.
Once you encounter serious difficulties working and have to go on what may be long-term sick leave, complete the application at that point, even if you are able to continue working on a part-time basis. This will prevent the insurer from claiming that your time of disability began when you started on sick leave, not when you stopped working. It will also prevent the insurer from claiming your rate of pay is based on the hours worked without consideration of your sick pay.
Disability insurers have a legal obligation to decide claims fairly and promptly. If a disability insurer does not allow payment of a properly proven claim, it will be ordered to pay the benefit and may be ordered to pay additional damages for the stress that you have suffered and other losses associated with the denial of the benefit.
Despite their legal obligations, disability insurers are businesses. The fewer disability benefits paid, the higher the bottom line profit. Disability insurers realize that after an impressive sounding denial letter, many claimants will give up and not pursue the claim any further. A disability insurer incurs almost no risk in making an initial denial of a claim. The disability insurer will usually allow a claimant the right to make an internal appeal of the denial of the claim and even encourage the claimant to supply additional documentation in support of the claim. These appeals are almost never granted. A disability insurer may claim that the denial is objective by stating that the claim evidence was examined by a person with medical qualifications.
Experienced Legal Representation & Disability Insurers
You should not accept the denial of your claim by a disability insurer acting in its own self-interest. No matter how impressive the reasons given by the insurer may sound, if your disability prevents you from working, have your claim reviewed by an experienced disability insurance lawyer in Newfoundland, like Geoff Aylward.
An experienced disability insurance lawyer can help make sure that the best medical evidence is gathered in support of your claim. This will be considered together with a full understanding of the nature of your job. Your work experience, education, age and training can also become important factors as the claim progresses. It is important that the insurer realize that it is up against an experienced disability insurance lawyer who will present your case in the best light with the proper legal arguments backed up by the necessary medical reports, documents, and other records. Usually, it is possible to persuade the disability insurer to either pay benefits, reinstate benefits or settle the claim on a lump sum benefits. If your claim has merit, the disability insurer will take a far different approach to it if you are represented by an experienced disability insurance lawyer like Geoff Aylward.
An experienced disability insurance lawyer is used to dealing with the standard insurance denial arguments. These arguments include:
- Medical opinion does not prove disability or provide a sufficient diagnosis to support disability.
- There are incomplete medical records.
- Application is insufficient to prove "total disability," or you do not fall within the definition of "totally disabled."
- There is no "objective" proof of disability; the disability is based on subjective complaints of pain.
- You do not meet the policy's definition of “total disabled” especially on the "any occupation" basis.
- You have an excluded or preexisting condition.
- A medical opinion by an insurance expert states you are not totally disabled.
- There was a failure to follow recommended care or treatment that the doctor ordered.
- There was a failure to participate in a rehabilitation program prescribed by the insurer.
- You did not receive a proper diagnosis, or did not receive a diagnosis altogether.
- You received the proper care or therapy, but the medical personnel did not supply accurate documentation.
- You are not under the regular care of a doctor.
- You have not complied with certain terms of the policy.
- Other terms of the policy are interpreted by the insurer in a way that denies you coverage.
An experienced disability insurance lawyer like Geoff Aylward knows how to prevent insurers from improperly hiding behind these arguments in cases where they do not apply.
If your doctor has diagnosed you with a mental or physical condition that prevents you from working, check with an experienced disability insurance lawyer if you are left with questions about why your claim is denied. Do not accept the insurer's explanation for its denial because that denial is made in the best interests of the insurer. Speak to an experienced disability insurance lawyer who will consider the claim from your best interests.
Comprehensive, Experienced Insurance Dispute Lawyer in Newfoundland and Labrador
If you have been disabled, you have rights. If you have been denied disability benefits, your rights may have been improperly violated. Disability insurance dispute lawyer Geoff Aylward offers strong advocacy and legal counsel in your fight to obtain the compensation you are entitled. He focuses on personal injury, insurance dispute and malpractice matters in Newfoundland and Labrador. He knows how to deal with the tactics used by insurance companies to stall and deny claims.
Equipped with experience, keen insight, and compassion, lawyer Aylward is available during and after business hours to address your disability insurance concerns. He can be reached after hours by text at 709-743-1708 or by email at [email protected].