Applying for Disability Benefits in Ontario: A Step by Step Guide

If you've suffered a serious illness or injury and find yourself unable to work and you have access to disability benefits, you may be considering making an application for short-term and/or long-term disability benefits.

This blog post will discuss the application process and what you need to know about applying for disability benefits. But before we get into that, it's important to remember that your insurance company assesses your claim according to the policy definition of disability.

Under most short-term disability policies, the definition of disability is whether you can perform the duties of your own occupation. Under most long-term disability policies, there are two definitions of disability; own occupation and any occupation. Usually the own occupation period is for the first 2 years of benefit payments and you have to demonstrate you are unable to perform the duties of your pre-disability employment. After that, the definition changes and you have to show you are unable to work in any occupation that you are qualified for, by education, training or experience.

The Application Package

The application package usually consists of three documents:

• The Employer Statement (also known as a Plan Sponsor Statement)
• The Employee Statement (also known as a Plan Member Statement)
• The Attending Physician's Statement

The Employer Statement/Plan Sponsor Statement

Your employer is responsible for completing this part of the application.

Important information asked of your employer includes:

• Your job title
• A description of your job duties (they may also provide a separate job description)
• Your last day worked
• Your salary/earnings
• If there is more than one benefit class in the policy, which division you fall under
• How many hours you worked in a typical week
• Whether you required any accommodations before going off work
• Whether there were any performance issues or concerns
• Whether there were any workplace issues/conflicts

Your insurance company requires this information in order to establish your date of disability, when benefits would commence and to determine what your benefit amount will be.

The information provided by your employer also helps your insurer determine what your own occupation is and your regular duties/responsibilities.

The Employee Statement/Plan Member Statement

You are responsible for completing and submitting this form. This form is your opportunity to describe your condition in your own words and provide information about your treatment and response to treatment. You can indicate if you are waiting for further specialist appointments or specialized treatment.

You also will be asked to provide information about your symptoms and what you feel are your barriers for returning to work.

You will be asked to describe your job duties.

Other information you will be asked to provide includes your education, training and experience.

The insurance company wants to gain an understanding into your condition and your transferable skills.

The Attending Physician's Statement

This form should be completed by the physician who is most familiar with your condition.

This form is where your doctor can describe your condition in detail and provide crucial information such as:

• The date you started showing symptoms
• Your diagnosis
• Description of your symptoms, both objective and subjective
• Clinical observations
• Description of your restrictions (things you should not do) and limitations (things you cannot do)
• Recommended treatment and your response to treatment
• Your treatment compliance (i.e. going to physiotherapy, taking medication)
• Any pending consultant appointments or tests
• Your prognosis for recovery
• Your ability to return to work at your own job or any job
• Whether you will benefit from a gradual return to work program or rehabilitation program arranged by the insurer
• Any factors complicating your recovery

The insurance company puts a lot of weight on medical evidence and it is important that you are always honest with your doctor (s) about your symptoms and activity levels/abilities. You should be aware that your insurance company is looking to see if you are under the care of a physician appropriate for your condition and are receiving appropriate treatment, at an appropriate frequency.

The Functional Telephone Interview

As part of the application process for short-term or long-term disability benefits, the case manager assigned to your claim will contact you for an interview. This is usually referred to as a "functional telephone interview" because your insurance company is looking to gather information about your functional abilities and how your disability affects your overall functioning.

Questions that might be asked of you include:

• What were the events that led to you going off work?
• What are your daily symptoms?
• What kind of treatment do you attend and do you find it helpful? (including medication)
• What doctors are you seeing/have you seen?
• What is your highest level of education/what additional training have you completed?
• Previous employment experience
• What does a typical day look like for you?
• Describe your barriers to returning to work
• How do your symptoms prevent you from performing your work duties/job responsibilities?

This type of information is required as your case manager is looking to see if the medical information matches your description of symptoms, restrictions/limitations and to determine what your activity levels are and how that correlates to your symptoms.

The functional telephone interview is an opportunity for you to ask questions about the claim process and an opportunity to provide any additional information you feel may be helpful for your claim.

Requests for Further Information

In some cases, the case manager will feel that further medical information is required in order to make a decision for your claim. They may write to your doctors directly to obtain such information as clinical notes and records and specialist records for a specified time period (e.g. the date of disability to present) and/or ask them to answer some questions to clarify your diagnosis, treatment, restrictions and limitations and prognosis.

Internal Medical Review (Medical Consultant Review)

Your insurance company has medical consultants who conduct file reviews to help case managers make a decision on claims. Your case manager may request that an internal medical consultant review be conducted to better understand your condition. Your case manager will ask them very specific questions.

Common questions asked include:

• Is the diagnosis supported?
• What are the supported diagnoses?
• Are there medically supported restrictions and limitations?
• Does symptom severity correlate to clinical findings?
• Is treatment appropriate?
• Is there anything prolonging the condition?
• Are there any barriers to returning to work?
• Is further information required?

The medical consultant review is a paper review and the person completing the review will not have direct contact with you. Their opinion is based on the documentation available.

Claims Decision

After the case manager has received all the requested documentation and the response from the medical consultant (if applicable), they make a decision on your claim.

They will call you to notify you of the decision they have made in addition to sending you a letter with the decision.

The outcome can be that your claim was approved, your claim is pended as further information is needed, or your claim was denied.

Your claim could be denied for a variety of reasons, but most commonly it is due to lack of objective medical evidence and that there are no medically supported restrictions or limitations. Other reasons could be that you are not receiving proper treatment or under the care of an appropriate physician or you should be able to attend treatment while continuing to work. 

If your claim for STD or LTD benefits has been denied for any reason, we can help you. We have assisted many clients who went off work for a variety of conditions/illnesses or injuries to successfully resolve their claims.