If you work for an employer that provides group benefits, you may have long-term disability (LTD) benefits as part of your benefits package. Some employers also have an additional LTD policy to cover workplace illnesses/injuries, called an occupational long-term disability policy.
There are some similarities and differences between occupational policies and group policies.
This blog will cover the following:
In Ontario, employers in certain industries are required to have coverage under a workers’ compensation plan (e.g. WSIB). There are some companies (e.g. banks) that have an occupational long-term policy in place to cover workplace illnesses and injuries that may have ordinarily been covered under a provincial workers’ compensation benefits.
An occupational policy is used for mental or physical illnesses or injuries that are specifically related to the workplace.
Both types of policies have a definition of disability you must meet to qualify for benefits.
Both policies usually have 2 different definitions of disability, an “own occupation” definition which concerns your ability to perform the essential duties of your occupation and an “any occupation” definition which concerns your ability to work in an alternate occupation for which you are qualified by way or education, training or experience.
Under any LTD policy, you must endure a “waiting period” or “elimination period” before benefits can be paid to you. An elimination period can be anywhere from 15 weeks to 52 weeks.
Both policies have offset provisions, meaning other types of benefits can be used to reduce your monthly LTD benefit amounts (i.e. Canada Pension Plan Disability Benefits).
Both types of policies require you to have been actively working and performing all your usual, expected duties for your scheduled shifts/days/hours at the time of the onset of disability (you need to be an “active” employee).
Both types of policies require you to be under reasonable treatment for your condition. This means you need to be seeing your doctor/specialist as often as is typically required for your condition.
Both types of policies have a rehabilitation clause, which requires you to participate or make best efforts to participate in rehabilitation arranged by your insurer (i.e. a treatment program or a return to work program).
Both policies set out certain responsibilities for the insured person including the expectation that you will recover from your disability by participating in treatment/rehabilitation, try modified duties, obtain retraining, apply for other benefits available from other sources such as Canada Pension Plan Disability Benefits.
The benefit amount under an occupational policy is usually a higher percentage of your monthly income as it is comparable to the provincial workers’ compensation benefit amount, which in Ontario is 85% of your monthly earnings.
The criteria for the definition of total disability under own occupation differs. Under an occupational policy, you must be unable to work due to an illness or injury arising out of and in the course of your employment. Some policies may indicate that you must be unable to do any occupation within the company you work for, that you are or may be reasonably qualified for that would equal 100% of your pre-disability income.
The own occupation period may be longer under this type of policy and may be a stricter definition.
To be eligible for benefits under this policy, you must provide acceptable evidence that you became totally disabled due to an occupational illness while covered under the group policy, and as with under the group policy, you have to show that your disability continued past the waiting period and you are seeking appropriate treatment etc.
There could be a difference in taxable status, for example, you may pay the premiums for your group policy, meaning your benefit is not taxable, and your employer pays the premiums for the occupational policy, making the benefit taxable.
If you have coverage under both a group LTD policy and occupational LTD policy, it is important that you obtain a copy of both policies, so you can understand what type of benefit you are entitled to.
Here are some things to take into consideration:
If your LTD claim is denied, either at the outset, or at any point in time, a lawyer can help you to fight the insurance company’s decision to deny/terminate benefits.
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