|
|
SHORT AND LONG TERM DISABILITY
Plan ahead. We have all been given this advice
at one time or another. One way to plan ahead is
to take an employment position that offers short
and long term disability coverage. This gives us
the peace of mind that, in the extremely unfortunate
event that we are injured to the point where we
can no longer work, we are not left without any
source of income to cover our daily expenses, like
a mortgage, rent, groceries, or hydro. For those
who are not offered disability coverage through
their employer or if they are self-employed, a private
disability policy might be purchased. The theory
is that with this kind of peace of mind insurance,
we can rest easy; we will be covered in the case
of an unforseen serious injury or illness.
One might expect that there would be little need
for a lawyer to protect your rights; it should be
as simple as “if I can’t work, my insurance
company starts to make the payments described in
my policy.” Unfortunately, pursuing long term
disability claims can sometimes lead to more frustration
than peace of mind. There are numerous disputes
that can arise between you, the individual unable
to return to work, and the disability insurance
company. A brief overview of some of the issues
that frequently arise quickly sheds light on the
complexity of this area of insurance law:
the definition of ‘disabled’: many
policies require that the insured suffer “total
disability”. What does this mean? Does a concert
pianist that has one finger amputated meet this
definition? She can still play the piano, but not
as she did before. Is she entitled to disability
benefits?
-
the
definition of ‘disabled’: many policies
require that the insured suffer “total
disability”. What does this mean? Does
a concert pianist that has one finger amputated
meet this definition? She can still play the
piano, but not as she did before. Is she entitled
to disability benefits?
-
disability
from your “own occupation” or “any
occupation”: many policies will pay you
disability benefits if you can not return to
your own occupation, the job you were doing
at the time of your disability. This will only
last for so long, typically two years. After
two years, you then have to show that you are
unable to perform any occupation for which you
are reasonably suited by looking at your education,
work experience and any other training. If the
concert pianist is no longer able to perform,
but now must now must earn an income teaching
piano to children, at half the pay, does she
still satisfy the test of “any occupation”?
-
time limits on claims: most disability insurance
policies discuss by when claims must be started
or else be entirely barred. Some policies suggest
that claims must be started within one year
of a denial. The Limitations Act suggests that
the general limitation period of two years would
apply from discovery of a cause of action (typically
a denial of benefits). Which time limit applies
to your denied claim? When is a claim actually
denied? Is a claim denied if the insurance company
has stopped paying, but has also said that you
have a right to appeal their decision?
-
proving entitlement: at the outset of a disability
claim, the claimant must rely on a brief application
of only a few pages to be submitted to the insurer.
This form is typically completed by your family
doctor and is the initial medical document that
supports entitlement. What happens if the insurance
company asks for clinical notes and records?
Typically the insurer will take the position
that the claimant has to pay for the documentation.
What if the cost is exorbitant? What if your
family doctor’s office is extremely busy
and fails to respond to the insurer’s
request in a timely fashion? What if the insurance
company forces you to see a specialist that
they have hand-picked, and that specialist determines
that you do not satisfy the disability definition?
Will your family doctor send you to an OHIP
paid specialist, which could take a number of
months? What do you do to cover your day to
day bills in the meantime?
Disability
litigation can be extremely frustrating and demoralizing
to the people most in need of help. If you are unable
to work and do not believe that your insurance company
is providing the peace of mind insurance that you
had expected, speak with a lawyer to ensure that you
can focus on trying to recover from your injury or
illness and let someone else, experienced and qualified,
deal with the insurance company.
|
|
|
