Long Term Disability Benefits

Long term disability (LTD) benefits are based on the provisions outlined in your group insurance policy. In most instances

• During the waiting period and the following 24 months, an insured member is considered disabled if, because of illness or injury, the member is unable to perform the significant duties of their own assignment.
• After this 24 month period, the member is disabled if, because of illness or injury, the member is unable to be gainfully employed

  Gainfully employed.

  Gainfully employed is defined as work that you are medically able to perform for which you have at least the minimum qualifications and make at least 60% of your earnings.

Application Process:

Three forms are required to initiate an LTD claim:

• Member's Statement
• Plan Administrator's Statement
• Attending Physician's Statement

You can get these forms from:

• Your School Board
• Your Union affiliate or
• An OTIP representative

The Initial Assessment includes:

• The review of the 3 claim forms
• An initial telephone interview

  Initial telephone interview

  The goal of a member interview is to 'fill in the blanks'. It is an opportunity for both the member and the disability analyst to share information related to the member's application for disability benefits and to discuss the adjudication process and what the member can expect.

  with the member
• Adjudication of the medical information provided

Tips for submitting your LTD application

When submitting your application for LTD benefits, please include the following items, if available:

• Copies of any medical documentation related to your present condition (including consultation reports, tests results and x-rays)
• A copy of your auto insurance claim file and accident report, if your claim is related to a motor vehicle accident
• A copy of your Workplace Safety Insurance Board (WSIB) claim correspondence and present status, if your claim is the result of an injury at work

The Claims Decision will be communicated to you verbally and in writing.

If the decision is to decline benefits, the reasons for the denial will be explained.

If you wish, you may appeal

the group life and disability claims decision.

If you choose, OTIP disability services representatives (DSR) are available to assist you in preparing your appeal.

Calculation of Benefits

Providing you remain totally disabled as defined by your contract, benefits are paid:

• During the first year on a per diem basis

  Per Diem means that during the first year, benefit payments are calculated on a per day basis from the members benefit start date to the end of August 31st.

   

  For example:

  Salary divided by total # of working days in the school year x LTD benefit % = LTD per diem rate

   

  LTD per diem x # of days remaining in the school year divided by # of months within this period = monthly LTD benefit payable.

  , with equal monthly payments until August 31st.
• Commencing in September during the second year of benefits payments, on a 1/12 basis

  1/12 Basis means that benefit payments are calculated on a monthly basis.

   

  For Example:

  Salary divided by 12 months x LTD benefit % = monthly LTD payable

CPP Benefits

Your LTD insurance provides for the integration of benefits when Canada Pension Plan (CPP) disability benefits are approved. You may be asked to apply for CPP benefits. In most cases your LTD plan directly offsets any benefits paid to you, as a contributor, from CPP.

An OTIP disability service representative (DSR) is available to talk to you about the importance of applying for CPP disability benefits and to assist you with completing your application. The DSR will also act as your representative during the reconsideration and tribunal process. See the Appeal Process section for more information about OTIP DSRs.

Ongoing Claims Management

Once your claim has been approved, the disability analyst will monitor your medical condition on an ongoing basis. The frequency of these follow-ups will be dependent on the your medical condition. Normally, the analysts request a progress report every 2-6 months.

Some Case Management Tools used by OTIP include:

• Medical Requests: writing the member's medical practitioners directly for updates
• Medical Advisors: to aid in the interpretation of medical provided as needed
• Independent Medical Examinations

  Independent Medical Evaluations (IME) – In some instances the medical information received by the disability analyst is minimal and a second opinion may be needed to provide additional clarification on the member's diagnosis, treatment and prognosis.

   

  1. IME Practitioners are unbiased specialists in their field of practice and are not employees of OTIP. The IME practitioner:
     • Reviews all medical submitted to OTIP, prior to meeting with the member
     • Has one (or more) face to face appointment with the member
     • Provides an unbiased report to OTIP based on his/her expertise related to member's condition and his/her observations
  2. The results of the IME are shared with the member's treating physicians.
• Surveillance

  Surveillance - At times, based on information provided, the disability analyst may notice an inconsistency between the member's diagnosis and their apparent level of activity. In these specific cases, surveillance may be done. Surveillance provides the disability analyst with an objective visual presentation of the member's actual level of activity and their abilities

OTIP group life and disability claims, supports and encourages rehabilitation efforts when you have been unable to work because of illness or injury. Rehabilitation Services are available during the LTD waiting period and during the course of the claim.

• Early Intervention
• Ongoing Rehabilitation Services

The Appeal Process

If your claim has been denied or terminated you are given the opportunity to appeal the decision. You also have the choice to use the services of an OTIP disability service representative (DSR) to help you with your appeal.