A Closer Look At Short-term Disability Benefits In Ontario

Employers may offer various benefits as part of your group benefits package, including short-term and long-term disability benefits.

When you fall ill or sustain an injury that leaves you unable to work for a period of time, applying for disability benefits can seem overwhelming and like a monumental task. Insurance policies can appear to be complex and difficult to understand. It might not be clear what type of information the insurance company is looking for in order to approve your claim.
​
This blog will explain what short-term disability (STD) benefits are and key information you should know about STD benefits and STD claims.

Important Facts About Short-term Disability Claims

The Waiting Period

​The waiting period for short-term disability benefits is short relative to the waiting period for long-term disability benefits. For example, it can range from 1 day to 1 week and is dependent on the policy.

How STD Benefits Are Paid

STD benefits are paid weekly and pay a percentage of your weekly earnings for a specified duration of time if you are unable to work as a result of illness or injury.

How Long Are STD Benefits Paid For?

Short-term disability benefits are only paid for a defined period of time. The period for which STD benefits can be paid ranges from 15 weeks to 52 weeks and is dependent on your policy.

How STD Benefits Are Calculated

1. STD benefits are calculated based on a percentage of your weekly earnings. The exact percentage is set out in your policy. It is important that you are aware of what your weekly earnings are, so that you can make sure your benefit has been properly calculated. Your benefit can range from 50% to 100% of your weekly earnings.
2. Under some polices, where STD benefits are paid for example, for 52 weeks, the formula for payment can vary for the period and be 100% for the first 6 weeks, 75% for the next 6 weeks and 55% for the remaining 40 weeks.
3. Some employers offer the employee an opportunity to “top up” their coverage for STD benefits and change from what is known as a “core plan” (basic plan) to an optional plan so that they may receive a higher percentage of their weekly income if they go on short-term disability leave.
   

What Medical Evidence Is Needed?

​As with any type of disability claim, the insurance company is looking for medical evidence that substantiates your disability and shows evidence that you have medically supported restrictions and limitations. Does your medical evidence show how your illness or injury or condition impacts your ability to perform the essential duties of your position.

Who Pays The Benefit?

​Sometimes your employer has an arrangement with the insurance company known as an Administrative Services Only agreement, where the insurance company adjudicates the claim, but your employer is responsible for paying the benefit. The insurance company advises your employer if benefits are approved, should continue to be paid and when they are denied. However, the insurance company is not allowed to release confidential medical information to your employer.

Can You Fight A Denial Of Benefits?

A denial of benefits at any stage of the claim can be appealed, however you have the right to retain a lawyer to commence a legal action against the insurance company. If your benefits have been denied, you should contact an experienced disability lawyer as soon as possible to determine the best course of action.

What Happens When My STD Benefits End?

In recent posts we have discussed short-term disability benefits in detail, including the differences between short-term disability (STD) and long-term disability (LTD) benefits.
​
If you are a disabled employee who has access to both short-term disability (STD) and long-term disability (LTD) benefits, you may be wondering how these two benefits integrate. This blog post will provide a brief overview of what happens when your STD benefits transition to LTD benefits. 

Who Assesses My Claim?

Some employers have two different providers for short-term disability benefits and long-term disability benefits, and most insurance companies have difference case managers (claims adjudicators) for STD claims and LTD claims. For example, some employers choose a third-party company to administer the policy and make decisions about the STD claim while the employer pays the benefit (known as an “administrative services only” contact) and other employers have the insurance company administer both claims.

What will typically happen towards the end of the short-term disability period is that your short-term disability case manager will send your claim for an “LTD Transition Review” by sending your medical documentation and your information to a long-term disability case manager.
​
Ideally, this would be completed within a reasonable timeframe so that if you are approved for LTD benefits, your benefits would commence on time.

How Is My Claim Assessed?

When your claim is being assessed for eligibility benefits, the case manager is looking to see if you meet the test for total disability during the waiting period, which, if you have STD benefits, is the maximum amount of time benefits would be paid for.

The definition of disability during the STD claim is usually whether or not you are able to perform the essential duties of your own (or similar) occupation. The definition of disability during the initial part of an LTD claim is typically the same; concerning your ability to work in your own occupation.
​
The case manager is looking for medical evidence that supports your reported symptoms, limitations and restrictions.

Do I Need To Make A Separate Application For Long-Term Disability Benefits?

​Due to recent case law, it is important that you ensure a complete LTD application is being submitted to your insurance company so that you do not forfeit your right to benefits. If the end of the waiting period is nearing and you have not been provided with LTD forms from the insurance company, you should request an LTD application package (if it is a different provider than your STD insurer) or an LTD transition package (if it is the same insurer). You must submit your Member’s Statement and Attending Physician’s Statement within a timely manner, in accordance with your policy. It is of utmost importance that you review your policy to find out how long you have to make an application.

Will My Benefits Start On Time?

• When your LTD benefits start will depend on a variety of factors including:
  When the STD case manager transferred information to the LTD case manager (or insurance company, if different) and how long it takes them to review it
• If further medical information is needed other than what is in the STD file and an Attending Physician’s Statement, and if it has been provided in a timely manner
• If a medical consultant review is deemed necessary by the case manager
• When your complete application is submitted (the insurance company will need the Employer Statement or Transition Form to be completed as well)

What If My Insurance Company Arranged A Gradual Return To Work For Me?

Sometimes an insurance company may arrange what is called a “gradual return to work” program as they feel you are able to return to work on a graduated basis. This might occur at any point in your claim. It could occur towards the end of your STD claim and extend into your LTD claim. Your benefits may only be approved until the end of the gradual return to work program. However, you may not be able to participate in the program as your treating physician (s) do not feel you are ready to engage in work at that time or you may have tried it, and it exacerbated your symptoms.
​
If you are unable to complete a gradual return to work, it is important to provide your insurer with medical evidence demonstrating your functional limitations and how working exacerbates your symptoms/condition.

Why Might My LTD Benefits Be Denied?

Common reasons for denial of benefits may include:

• You did not satisfy the definition of disability during the waiting period
• Lack of objective medical evidence to support a diagnosis or symptoms
• Lack of objective medical evidence to support restrictions and limitations
• Failure to attend appropriate or reasonable treatment
• You did not participate in a return-to-work or rehabilitation program and it is believed you were medically able to
• No medical evidence was provided by your treating physicians (they did not respond to requests)

​You should know that you can fight the insurer’s decision to deny benefits.