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, LTD benefits provide income replacement when an insured member becomes ill or injured and is unable to perform the significant duties of their regular assignment.
- After this 24 month period, benefit payments continue if the member's medical condition prevents him or her from being
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.
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.
To appeal a decline or termination decision
- provide a detailed letter to OTIP group life and disability claims outlining your reasons why your claim should be reconsidered, and
- provide additional new information that may substantiate ongoing disability
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.
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
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 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 member 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 the member remains totally disabled as defined by their contract, benefits are paid:
- During the first year on a per diem basis, with equal monthly payments until August 31st.
- Commencing in September during the second year of benefits payments, on a 1/12 basis
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.
Ongoing Claims Management
Once a member's claim has been approved the disability analyst will monitor a member's medical condition
on an ongoing basis. The frequency of these follow-ups will be dependent on the member's 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.
- 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
- 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 a member has 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.
The Appeals Process
If your claim has been denied or terminated you are given the opportunity to appeal the decision.
- Initiating your Appeal
Initiating your Appeal
- You have 2 years for the date of the claims decision letter to appeal
- You are required to send an appeal letter outlining your reasons why your claim should be reconsidered
- New and/or additional medical information to support your claim should be submitted
- Any costs associated with the appeal are your responsibility
- Appeal Assessment
Appeal Assessment
- The appeal information will be reviewed by an appeals specialist
- If any additional information or investigation is required it will be obtained by the appeals specialist
- Additional investigations may include, but are not limited to:
- Clarification from your attending practitioner(s)
- An independent medical evaluation
- A functional abilities evaluation
- A medical consultant review
- Appeal Decision
Appeal Decision
- The appeal analyst may approve the appeal or send it to the Appeals Committee
- The committee may:
- Approve your appeal
- Request additional information
- Maintain the initial decision to deny or terminate your claim
- If the Appeals Committee maintains the denial or termination of your claim, and you still wish to pursue your claim, it is recommended that you discuss your options for binding arbitration or litigation with your Affiliate representative or legal counsel.
- Appeal Committee
Appeal Committee
- Is comprised of two senior representatives from the insurance company and one senior representative from OTIP LTD Services
- This committee makes an independent review of the claim and appeal and comes to a final decision.