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Health Insurance and Benefits

Applying for Long Term Disability

Many people diagnosed with cancer face the decision to leave work at some point in their journey.   Approximately 30% of Canadians have access to a Long-Term Disability (LTD) insurance policy and have the option of applying to this benefit when their leave extends beyond a temporary absence.

There is no obligation for you to disclose your diagnosis to your employer at any point, even when you file a claim for LTD.  Your obligation is simply to inform your employer of your inability (or anticipated inability) to complete your job.   You will be required to disclose your diagnosis to the insurer as part of the LTD application process, but the insurer is required to keep this diagnosis confidential and work on behalf of the employer in considering the claim.  The role of the insurer is to ensure all options to support you in continuing to work have been exhausted and that you meet the criteria for a long-term disability payment. 

Every LTD policy has an elimination period – a period of time where you must be off work and have exhausted your options short term illness benefits.  Depending on the policy, this could include your total number of sick days, your sick leave benefits, and/or Employment Insurance Sickness benefits.  You will not be able to receive LTD benefits until the elimination period has ended.

When you apply for LTD, you will be given a package of forms from your employer (or your insurance advisor if you have an individually paid plan):

One part of the package will be your application for benefits.  This is basic information you will need to fill out about yourself, including when you fell ill and when you needed to leave your employment.  The application will also ask you about the types of work you perform on the job and the length of time you work each week/month.   The insurer asks these questions to determine the type of work you need to fulfill so they can better determine the impact of your cancer on your ability to work.  

The other part of the package is your Medical Information.  This part needs to be filled out by your treating physician.   This may be your family physician or your oncologist.   Most insurers will prefer that your oncologist fill out the form whenever possible.   The insurer will be looking to confirm the following:

• Diagnosis
• Stage of disease
• Prior treatments (if any)
• Prescribed treatments and their intended impact
• Functional ability or level of impairment
• Support you are receiving for your impairment (e.g. medications, physiotherapy, home nursing, etc)
• Anticipated extent of illness (i.e. is it anticipated you may return to work)

It is your responsibility to ensure the treating physician completes the Medical Information forms.  Check first to see if the physician/oncologist charges to complete these forms.  Many do as the forms can take significant time to complete and the time is not compensated by public medicare.  If the insurer contacts you to say the Medical Information form has not been received, it is your responsibility to follow up with the physician.

If you feel you need to provide additional medical statements on your inability to work, you can include it at this point, but it is not always necessary.  This can include a statement from a treating mental health practitioner, a physiotherapy report, etc.  Keep in mind that any statements included in your application should speak to your inability to perform your work duties.  Cancer is stressful, and most people would prefer to be off work during their treatment, but to claim LTD means you must show you cannot do your job in your current functional state.

You may receive a call from the insurer’s claim specialist, or receive a request to meet with a LTD case manager after filing your claim.  This is normal procedure to allow them to gather more details about your case and clarify any questions.  The representative may also speak with the physician or oncologist who submitted the Medical Information form.   The claim specialist and/or case manager have specific training on certain diseases like cancer and are aware of the various treatments that are used.  They will be looking at all available evidence to support the claim that due to your disease, treatment and/or side effects, you will be unable to complete your normal work duties.

It takes several weeks for the LTD claim to be processed.   Most of that time is spent reviewing the details of your claim and verifying information.  There may be questions that arise from the claims specialist or case manager about whether you are able to continue at your workplace with modified work duties.  The insurer might also seek an independent review of your claim by an independent medical examiner if the physician or oncologist has not provided sufficient information about your ability to work.  Depending on your LTD policy, you may be asked to be examined by this independent medical examiner. 

To receive LTD, you must prove to the insurer that you are unable to complete your work functions even with modifications in place.  The job of the insurer is to work on behalf of the employer to ensure all evidence has been presented to show that this is indeed the case.

If your LTD Claim is Approved

Once approved, the payment is usually made to you once a month.  If the claim is approved part way through the first month, your first payment will be adjusted to a partial payment.  If the approval was delayed well past the elimination period or point of eligibility, you may receive retroactive payment.

If it is anticipated that you will not be returning to work, you may be asked by the insurer or employer to apply for CPP Disability.   If you do and this is approved, be aware that any other LTD benefits – CPP, Workers Compensation, etc – will be deducted from your insurance LTD dollar-for-dollar so you still end up with the same monthly amount.

The insurer or LTD case manager will be following up with you periodically to determine (1) if there are any changes in your disease or functional status and (2) (if appropriate) if you are able to return to work.  In completing these follow ups, the insurer will be looking to establish evidence that you still cannot return to work and may ask for updated medication information:  pathology reports, new physician reports, new treatment plans, bloodwork, functional tests, etc.  It is important to let this person know during these updates about any new impairments, symptoms, or illnesses that have developed over the course of treatment that further impact your ability to work.  Be specific and practical, don’t minimize your symptoms.

Your obligations under LTD are to: (1) provide the necessary information that is required to complete the LTD assessment, (2) participate in your prescribed treatment, and inform the LTD case manager if something has changed or is preventing you from participating (e.g. pursuing alternative or out of country treatment, infection, accident or fall, etc). and (3) follow through on actions that will support your recovery as best possible (e.g. attending medical appointments, exercising as able, getting enough sleep etc).

You are not required to report to your employer during the time you are receiving LTD.  The employer will, however, be contacted occasionally by the insurer to ask questions about the ability to accommodate your needs if you should return to work (e.g. schedule changes, modifications in workplace environment).

If you are Asked to Return to Work

If the insurer determines that you are able to start back to work on a trial basis following treatment, and you do not feel you are ready, you can ask for the information they used to make this determination.   Often, the medical information provided by your physician was not detailed enough to provide solid evidence that you cannot work even at reduced function.  You can also work with the LTD case manager on back to work “hardening” programs that allow you to gradually adjust back to the demands of a job.  If you are in complete disagreement with the insurer that you can return to work, you can appeal the decision.  Your LTD payments may be suspended until a decision is reached.   The appeal process will require you to submit additional clinical information from your treating physician or other supporting practitioners (e.g. a mental health therapist, occupational therapist, physiotherapist, etc) and may involve an examination by the insurer’s independent medical examiner.

If you return to your job at any point, you will be granted a recurrence period by the insurer.  Usually this is a period of 6 months.  During this time, if you are unable to function at your job duties, or have a recurrence of symptoms or disease, your LTD payments will resume without requiring a full re-application.  If you are receiving LTD and choose to do a different job that has lighter duties, it is best to check with the insurer or case manager how this may impact your benefits.  This work should be different from anything that would have been available at your original workplace (even with job modifications).  There may also be limitations on the policy about how much you can earn on top of the LTD payment before it would make it ineligible or be deducted from your monthly payment (e.g. some policies allow a claimant to earn 15-25% of their LTD benefit without penalty).  

If you do not Return to Work - After two years

Once your time on LTD has reached the two-year mark, your case will be reassessed on a new definition of “disability”.  To continue to receive LTD it now must be shown that you are unable to do ANY job for which you are reasonably qualified.  The focus will shift from examining simply your ability to return to your old job.  At this point, your treating physician may be contacted for new information and you may have to speak again with the LTD case manager. 

If your LTD Claim is Denied

If your initial LTD claim is refused, you can ask to appeal the decision with more information.  Be aware that there are usually specific time limits for submitting new information.  A common reason for an LTD denial is that you haven’t met the definition of being unable to work as defined in your LTD policy.  It could be that the Medical Information completed by the physician wasn’t detailed enough, or your interpretation of inability to work is different from the insurer’s.   In re-submitting information – be specific and ensure your treating physician has provided enough details on your treatment and its impact on your ability to work.   Discuss this with your physician at a clinic visit if possible.  The insurer may ask you to be examined or may have your case reviewed by an Independent Medical Examiner at this point.

If your claim is denied again after re-submitting the information, you can ask to appeal the decision.  An appeal tribunal is a panel of representatives from the insurer as well as independent consultants who will hear your case.  The information you re-submitted, as well as any additional information you collect from other relevant health professionals involved in your treatment, is presented.  This can be a stressful experience as the onus is on YOU to present the information and prove why you cannot work.   There are some community support organizations that can provide support to you in preparing such an appeal.

You can also consult legal counsel on whether to appeal the LTD decision.  This can be done through your union or independently.  There are lawyers who specialize in health and disability claims.  If you hire a lawyer independently to pursue and appeal, the lawyer may charge per hour or charge you a percentage of the LTD amount that is awarded to you.  This lawyer will most likely seek independent medical consultants to review your case and/or examine you. 

It is important to keep in mind that if you do choose a legal appeal on an LTD decision, that it could take a year or more to resolve.  During that time, you could be laid off from your job as not meeting the terms of your contract.  Before you pursue a legal appeal, understand your options from your union or employer and weigh the time and expense involved carefully.

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