LTD Claims FAQ

In long term disability (LTD) contracts, disability is usually defined in two ways.

First Definition

• Covers the waiting period and the next two years
• Typically, it would read: "You are considered disabled if, because of illness, injury or disease, you are unable to perform the significant duties pertaining to your specific assignment."

Second Definition

• Normally related to a member's medical condition after the waiting period and the initial 24 months of benefits
• The definition now changes to: "You are considered disabled if illness or injury prevents you from being gainfully employed."

The difference between these definitions is important. Check your LTD contract to determine the definitions of disability that apply specifically to you.

The waiting, or elimination, period is the time between the onset of a disability and the date LTD benefits become payable. The waiting period starts when the member first becomes disabled and ceases work.

Depending on the LTD contract, the waiting period lasts for a specific number of calendar or working days. If disability is not continuous, the days the member is disabled and absent from work are accumulated to satisfy the waiting period, as long as there are no interruptions greater than 20 consecutive working days and the disability arises from the same illness or injury. The 20 working days changes to 30 calendar days when the waiting period is calculated on a calendar day basis.

In the standard OTIP LTD contract, a pre-existing condition means: disability arising from illness or injury for which you obtained medical care during the 90-day period before you became insured. Medical care is considered to be obtained when you consult a physician, use medication on the advice of a physician, or receive other medical services or supplies.

A pre-existing condition does not apply if disability starts after:

• You have been continuously insured for one year; or
• You have not had medical care for the illness or injury for a continuous period of 90 days ending on or after the date the insurance took effect.

If you are insured under a flex plan, the pre-existing condition provision applies to any changes in your benefit coverage during any flex review change period as provided in your flex plan LTD policy.

When a member's salary increases during the waiting period, the LTD benefit is calculated on the new salary. However, if the increase in salary occurs after the waiting period has concluded, the LTD benefit is based on the salary in effect at the end of the waiting period.

In the case of an integrated waiting period plan, the salary used for benefit purposes is the salary in effect on the date of the expiration of the member's sick leave credits.

Yes, as long as the school board allows for this administrative practice. A member cannot receive sick leave credits and LTD benefits at the same time. The member must repay the sick leave credits for the period that overlapped the LTD benefit, except for integrated plans. If the board will not allow the member to pay back the sick leave credits, this income will be offset from the LTD benefit.

The LTD plan is designed to provide benefits to members who are disabled as a result of illness or injury and are unable to work. The key word is "disabled" and disability is defined in your LTD contract. Members claiming LTD benefits must submit medical evidence to prove they meet the definition of disability outlined in the LTD contract.

All claims submitted to the claims office are adjudicated to determine whether they meet the criteria in the LTD contract. The adjudication process may include a member telephone interview, a thorough review of the medical data submitted and direct contact with the member's physician(s) to gather new information. It may also include a discussion with the employer to assess the potential for a modification to the member's specific assignment to accommodate an early return to employment. The adjudication process helps ensure the assessment of the reported disability is accurate and fair.

See also "What is the definition of disability?"

As part of OTIP's value-added service, our group life and disability claims representatives conduct a "without prejudice" review at the eight-week point. The goal is to adjudicate a complete claim submission within this time frame and provide the member with a verbal explanation by telephone, followed by written correspondence.

OTIP's standard LTD plan provides benefit levels as a set percentage (i.e. 50%, 55%, 60%) of your salary. Your benefit formula is listed in your plan. In some plans, the LTD benefit is limited to a maximum of a set percentage (i.e. 85%, 100%) of your gross or net take home pay. Please refer to the Table of Benefits in your LTD plan for more information.

No. Benefits arising from waived life insurance premiums will not reduce your LTD benefit.

No. Your benefits will not be affected by creditor insurance benefits.

When a member pays the full LTD premium, the benefit is non-taxable. When the employer contributes any portion of the LTD premium, the benefit becomes taxable.

You can continue to receive LTD benefits as long as you meet the definition of disability outlined in your contract. LTD benefits cease when you reach the maximum benefit period. In standard plans, this is the end of the month in which you reach age 65 or the date you are entitled to a 66% unreduced service pension from the Ontario Teachers' Pension Plan Board (OTPPB), whichever comes first. For OMERS, the maximum benefit period is specified in the Table of Benefits of your LTD plan. Please refer to your LTD plan for more information.

A disability recurrence provision in LTD contracts provides members with protection in the event they become disabled, or their condition deteriorates following a return to work. You must be disabled from the same or a related illness or injury within a specific time frame. The time frame varies from 100 working days to 6 months, depending on the plan. Please refer to your LTD plan for more information.

Yes. The 24-month own occupation disability definition change date will be extended by two months.

No. OTIP will re-assess your status 16 months following the date your benefits start. OTIP's decision to continue or terminate your benefits will be based on your medical condition and the definition of disability in your LTD contract. However, the definition of disability does change at the 24-month point. Entitlement to LTD benefits beyond 24 months changes from being unable to return to your previous role in education, to being unable to be gainfully employed in the workforce.

The assessment of disability beyond the initial 24-month LTD period changes from your inability to return to your previous role in education to your inability to be gainfully employed in another occupation.

OTIP's disability analyst assesses your degree of impairment and your pre-disability income. The analyst may even conduct a labour market survey to identify potential jobs within the province that you could perform, although the availability of work is not a factor in determining whether a person can, or cannot be gainfully employed. The information collected by the analyst is used to assess your capability to return to gainful employment. OTIP cannot actually find a job for you.

The 30-day termination notice begins on the day OTIP's letter terminating the benefits is dated.

Members should immediately contact an OTIP disability service representative (DSR). The representative will review the situation thoroughly, and if necessary, will meet with the member to provide appropriate guidance and direction.

The answer to both questions is yes. Any earnings, regardless of the amount, must be reported to OTIP. These earnings will be considered when calculating your LTD benefit.

Prior to considering legal action, you should review the claim decision with your disability service representative (DSR). Your DSR will thoroughly review the circumstances surrounding your claim and help you better understand how your claim was assessed. They can also provide you with helpful information to assist you in making decisions regarding your claim.

Decisions to deny or terminate the payment of benefits on a claim may be reversed through the appeals process. Your DSR is available to discuss this process with you. Should your appeal be unsuccessful, further assistance may be available through your association or federation. Before undertaking legal action on your own, it is advisable to consult your union or your provincial association or federation.

Notwithstanding the above, anyone who disagrees with the decision to deny or terminate the payment of benefits on their LTD claim has the right to take legal action at their own expense.

Based on the definition of disability in your LTD plan, eligibility for benefits is determined by assessing the medical information submitted in support of your claim. Under OTIP's standard LTD plan, you are considered disabled if your illness or injury prevents you from performing the significant duties of your specific assignment, i.e. 60% of your regular duties.

You would not qualify for benefits if your medical condition initially brought about only a slight reduction in your work schedule. However, if your condition deteriorated significantly, you could become eligible to receive benefits. If you reduce your work schedule for medical reasons, you should consider contacting OTIP group life and disability claims, or your disability service representative, to discuss your situation.

You would not be considered disabled in accordance with your LTD plan as long as your medical condition does not prevent you from performing the significant duties of your specific assignment, i.e. 60% of your regular duties. Assuming that your medical condition does not worsen, your claim for disability benefits would not commence until you stopped working as a result of surgery. The 60 working day waiting period would start at that time.

There is no specific minimum period of time that a member must remain at work before coverage can be reinstated. Even if a member's return to work occurs after the deadline, the LTD coverage is reinstated. The only restriction is that any future claims following the member's return to work will be subject to pre-existing limitations for one year after reinstatement of the LTD coverage.

A member should not return to work without their physician's approval simply to meet the deadline for automatic coverage reinstatement. Returning to work too early may impede recovery and delay a normal return to work.

Contractually, LTD coverage will only be extended 60 working days beyond the end of the waiting period for denied claims. For terminated claims, coverage will be extended 31 days beyond the date benefits are terminated.

Following this time period, the LTD plan requires a member to be actively at work to be insured. In order to satisfy this requirement, the member must be fully capable and actively performing their regular duties.

LTD insurance is designed to provide members with a financial safety net. The plan will provide income and pension plan protection if you become ill or physically disabled and you are unable to return to work at the end of your leave. Continuing to pay your premiums while you are on leave will ensure you retain the same LTD coverage you currently have at work, even though you will be on leave. If you suspend your LTD coverage when you go on leave and you experience a disabling event that prevents you from returning to work at the conclusion of your leave, you will not be eligible for income or pension plan protection.

A member is responsible for providing proof of disability. They must submit a completed APS to initiate the claim process. Once the process is underway, OTIP group life and disability will pay for any additional medical information requested directly from your physician.

Members must be under the care of a licensed physician and the nature and frequency of the treatment must be appropriate for their condition. For example, if a member has a mental and nervous condition, a certified specialist, such as a clinical psychologist or a psychiatrist, must actively supervise the treatment program.

The definition of disability outlined in your LTD contract is a critical element in the disability analyst's assessment of an LTD claim.

Disability analysts specialize in assessing disability claims. They gather information about the member's duties and the extent of the restrictions imposed by their medical condition. The disability analyst reviews the information and the appropriate provisions outlined in the member's LTD contract to determine the level of disability associated with the reported medical condition. Your physician's role in the process is to provide accurate, verifiable medical and clinical information to assist the disability analyst in making a thorough assessment of your disability.

OTIP will not normally release medical information to a plan member. However, OTIP will review any such requests from a member and will also consider forwarding a copy of the IME to the member's physician. A written request to OTIP group life and disability claims, including the member's authorization to release the information to their physician, will start the process.

We recognize that physicians are busy, however OTIP requires detailed, accurate information regarding a disability to properly assess a member's claim. OTIP also needs periodic updates from the insured member's physician to monitor the member's status. The reporting frequency varies from situation to situation; however, the time between reports is usually two to six months. In some cases, reports are required more frequently to manage the LTD process effectively and to ensure that members receive adequate support.

Requests for detailed medical information can be frustrating, but accurate data is an essential component in managing your LTD claim. OTIP reserves the right to contact your physician for information, however, if you feel the requests for information are excessive, please discuss the matter with the disability analyst coordinating your claim, or if necessary, with their team leader.

Typically, OTIP relies on periodic updates from the member's treatment providers to assess the member's ongoing entitlement to LTD benefits. If additional information is required, an independent medical examination, or a functional abilities examination may be required to provide specific information about a member's condition. OTIP group life and disability claims has the right to assign a physician of their choice to examine the member as often as is reasonably required during the claim period. The examiner is an independent physician and not an employee of the insurance company.

Surveillance is a tool used by all insurers to compare a member's observed activities to their reported restrictions and limitations. It provides insurers with additional information in the absence of objective medical data.