As a medical professional you have likely spent many hours assisting patients applying for disability benefits, but what happens when you are the one that needs to make a claim for disability benefits?
The COVID-19 pandemic has placed inordinate levels of stress on healthcare professionals. Many medical professionals are suffering from burnout and are experiencing physical and mental health-related issues.
Now, more than ever, it is important to consider whether you have sufficient coverage and what to bear in mind should you need to submit a claim for disability benefits.
Ontario Medical Association Coverage
Coverage through the OMA is group insurance coverage, you are covered as part of a group rather than as an individual policyholder. The policyholder is the OMA. To be eligible for coverage you must be under age 65 and working in Canada on a full-time basis, a member of the OMA and:
- Actively practising medicine as a family medicine practitioner or a specialist;
- Employed in medical research, medicine and health sciences education or administration in connection with the profession of medicine;
- Training as a resident
- A postgraduate student, medical fellow or medical student; or
- Serving as a medical missionary.
Sun Life Assurance Company of Canada is currently the insurance carrier for the OMA and is responsible for adjudicating disability claims that are submitted under the Policy.
OMA coverage does allow for some customization in the form of Riders such as the Own Occupation Rider, GIB or Guaranteed Insurability Benefit Rider, COLA or Cost of Living Adjustment Rider and RPR or Retirement Protection Rider.
An Own OcThe cupation Rider changes the definition of disability to relate solely to the insured’s occupation at the time a claim for disability is made. GIB or Guaranteed Insurability Benefit Riders allow for the purchase of additional insurance over time without having to submit to a medical underwriting process each time additional insurance is sought.
Cost-of-Living Adjustment Riders index the disability benefits an insured is entitled to receive over time. The indexing usually occurs annually and may be tied into the percentages set out in the consumer price index (CPI), or may be a set percentage. Retirement Protection Riders provide for the payment of an additional monthly benefit into a locked-in, non-registered retirement fund.
The claims process requires the submission of several forms including a Member’s Statement of Disability, Initial Attending Physician’s Statement and Pre-Disability Business Profile. Benefits are calculated based on Pre-Disability Average Monthly Earned Income, which is typically defined in the Policy.
Once you have submitted a claim for disability benefits to the insurance company, they will assign your claim to an adjudicator (referred to as a case manager) who will investigate your claim to determine if you qualify under the applicable definition of disability set out in the Policy. The insurer may request extensive documentation including medical and financial information.
It is useful to speak with a lawyer at this point to determine whether the information you will be providing will provide you with the best possible opportunity for approval of your claim. It would also be important to analyze how pre-disability income is calculated under the policy in order to ensure that you maximize your benefit entitlement.
ch allow for payment of disability benefits when an insured is still working in their own occupation (i.e. not totally disabled) but not at full capacity and Lifetime Benefit Riders which ensure that policies continue
Individual Insurance Coverage
Individual or private disability insurance involves an individual contracting directly with an insurance company for the insurance coverage. There are a number of insurers that offer disability insurance policies specifically geared towards professionals. RBC Insurance (Professional Series), Canada Life, Manulife (Proguard Series) and Sun Life all have policy packages geared to professionals and higher income earners.
Individual insurance may allow for greater customization of coverage through the use of riders which include many of the ones referenced above as well as others such as Partial and Residual Disability Benefit Riders whie to be payable beyond the usual maximum end date of age 65. This is particularly important for professionals, who have a tendency to work beyond age 65.
When securing insurance coverage, it is essential to carefully analyze all the options available in the form of Riders and obtain a clear understanding of what each one will cover. Ensure that you secure the assistance of a knowledgeable broker. Brokers have an obligation in law to ensure that you are properly protected. Help your broker understand the protections you will require over time and your plans for the growth of your practice.
Broken Promises
Although disability insurance carriers make promises about the protections they offer, as disability lawyers representing professionals we are often privy to the times when these promises are broken.
Take for instance the Own Occupation Rider. Not all Own Occupation Riders provide the same level of coverage. An Own Occupation Rider with a clause that stipulates that the insured may not be gainfully employed in an occupation other than their regular occupation may prohibit a claimant from working in any other capacity after a disability claim has been filed.
An “Own Occupation Rider” that allows for a claimant to be employed in an occupation other than their regular occupation would mean that the claimant would be entitled to work in something other than their own occupation and still qualify for disability benefits coverage.
Many insurance companies promise medical professionals that they will have coverage if they are unable to work in their own highly specialized area but when a disability claim is filed, the insurer denies the claim on the basis that the medical professional can still perform portions of the specialty and is therefore not disabled.
We have seen claims denied on the basis that the medical professional cannot perform surgery for example due to a medical condition such as Parkinson’s but they can perform managerial or office work. Since the medical professional indicated that managerial or office work formed a portion of their occupation pre-disability, the insurer claims that they are not disabled due to their ability to perform office or managerial work and denies the claim.
We have seen insurers neglect to assess claims for all the benefits that an insured may be entitled to. For example, the insurer might fail to pay the Retirement Protection Benefits or fail to increase benefits annually under the Cost of Living Increase provisions.
Insurers might also apply the terms and conditions of the policy incorrectly or have a claim paper reviewed by an internal medical consultant who fails to consider all relevant medical evidence or cherry-picks portions of the medical evidence resulting in a denial or termination of benefits.
