Ah, the fine print. Lawyers always read the fine print because we so often need to refer to it in our cases.
But when many people see a block of legalese in two point font they simply shrug their shoulders, ignore it, or scroll past it to click the “Yes I have read all the terms and conditions” option and get on with their lives.
In this blog post, I look at the language used in long-term disability insurance plans, terms like “own occupation” versus “any occupation.”
Short-Term and Long-Term Disability
If an illness or other medical condition affects your ability to continue to work at your job beyond what your employer provides for in term of sick days, you may qualify for short-term disability benefits after a qualifying period. Depending on the insurance plan you have, these benefits may pay your full salary or, more likely, a significant percentage of your regular salary (about 70% on average) for a period of 15 weeks to up to a year.
Short-term disability benefits are usually contingent on medical reports from your medical practitioner which describe the nature and extent of the disability and a date they expect you will be able to return to work. After this point, if there appears to be no immediate expectation of recovery and re-entry into the workforce, a long-term disability option may be available.
When short-term disability benefits are set to lapse and a long-term disability plan is available, additional applications and medical examinations are usually required by insurance companies.
“Own Occupation,” “Regular Occupation,” “Any Occupation”
There is no standard definition of disability in Canada. It varies based on the illness/condition and can even vary among disability benefits policies. Moreover, even if you are considered to have a form of disability that warranted short-term benefits, your plan provider may not consider it sufficient to draw long-term benefits as the terms and conditions of each plan set out certain exclusions or rules that providers may apply to deny your application.
Many private plans require your disability to prevent you from working at “any occupation” for which your education, experience and skills are reasonably suited and where you can be “gainfully” employed. This threshold can be difficult to achieve, and you may find yourself denied coverage if you could hold other employment – even if it’s not in a role you would otherwise choose to do.
Some plans use the term “regular occupation.” If your disability prevents you from doing (all or the majority of) the duties and tasks associated with your regular position (normally your role when the disability manifested), you would qualify for LTD benefits.
Finally, some plans use the “own occupation” term.
An Unpleasant Surprise
Few people envision a day when a disability prevents them from doing their job or working entirely, but it happens more frequently than you might imagine. Some statistics suggest up to one third of people will face an illness or condition that prevents them from working for at least 90 days prior to retirement age.
Even if you haven’t needed to draw on disability benefits, talking to your insurance plan provider to review these terms and their specific meaning in your plan is always worthwhile. Remember to collect, save and, if possible, record all conversations, correspondence and forms. You may need to refer to them later or provide them to a legal representative if you have been denied coverage unfairly.
If you are already in the unfortunate position of having your benefits denied or learning that you are potentially going to be receiving a denial of benefits, you still have options. Lawyers with expertise in disability benefits can examine your case and may be able to make arguments based on the complex and undefined nature of these terms to help you access benefits you have been denied.
If you have been denied short-term or long-term disability benefits, or are looking for legal advice prior to making an application, please contact disability lawyer Brad Moscato at 416-646-7655, email at bmoscato@hshlawyers.com.
