When Injuries and Disabilities Strike: What You Need to Know About Income Replacement
When you are injured or disabled, long-term disability benefits (LTD) and Workplace Safety and Insurance Board benefits (WSIB) can help you financially.
Most members know these plans exist. But unlike dental or other extended health care benefits, LTD and WSIB are probably the least understood. Members struggling to deal with a medical illness or injury often find themselves overwhelmed by the associated paperwork. A little insight can go a long way in helping to alleviate the stress that invariably accompanies filing for benefits.
Disability is something most people don’t like to think about and consequently they know little about LTD and what it involves. As well, the process of applying for LTD can be confusing and overwhelming. Often members assume that paying premiums means they are automatically entitled to beneﬁts. Unfortunately, LTD does not operate like car insurance. Members sign up for LTD coverage but a member with a disability must apply for LTD beneﬁts.
The LTD process is made more difﬁcult by the fact that members are understandably very private about personal health issues. When they have to stop working due to a disabling medical condition, members often believe they will be returning to work soon and so won’t likely need to apply for LTD.
Comforted by a bank of sick leave credits, some will remain off work but will not actively pursue the medical help or treatment that might allow them to return to work sooner. And unfortunately, some are also so ill or devastated by the news of a disabling illness that they simply cannot focus on applying for LTD and do not realize that their local and/or school board can help them.
Steps to follow if applying for LTD
If you wish to apply for LTD beneﬁts you must do so no later than 6 months from the date of disability, which is the last date you worked on a full-time basis.
Before beneﬁts begin you must serve a waiting period, varying from 60 to 120 working days or the expiration of sick leave, whichever is longer, and depending on the LTD policy.
Insurance carriers generally recommend ﬁling an LTD claim after 20 days of absence from work. Pulling together the necessary medical documentation for the claim and allowing for the insurer to adjudicate it takes time. Applying for beneﬁts in a timely fashion is wise to avoid a gap between the end of the waiting period and the start of LTD beneﬁts.
Early Intervention program (EI)
Most LTD carriers have an optional Early Intervention program that gives you a number of alternatives focusing on your needs and enabling a timely return to work, all before the ﬁnalization of an LTD claim. Most EI programs (such as the one developed by the Ontario Teachers’ Insurance Plan) provide medical referrals, funding for equipment and support programs, referral to a rehabilitation counsellor, and other forms of assistance and resources as authorized by the insurance company. The program is conﬁdential and entirely voluntary. Your school board may also have an early intervention program.
LTD Claims Kit
The LTD claims kit contains three pieces of documentation that must be completed and returned to the insurer.
The Plan Administrator’s or Plan Sponsor’s Statement contains information about your salary and beneﬁts, job history, and a description of the work performed at the date of disability. The employer completes it; in many ETFO locals, a local representative completes this statementin consultation with the school board.
The Plan Member’s Statement allows you to report the nature of the disability, the severity of symptoms, and an explanation of why you cannot return to work. It is very important that the information you provide be consistent with that provided by your physicians.
The Attending Physician’s Statement gives the insurer with speciﬁc medical information about your illness or injury and prospects for returning to work. Your physician completes it in consultation with you. If you are seeing a specialist as well as a family doctor, you may also want to have the specialist complete a statement.
Rehabilitation, the process of helping you return to work, may start during the waiting period (before beneﬁts start) or anytime after beneﬁts begin. A vocational rehabilitation consultant will contact you to discuss your options.
A return-to-work plan may include a full or a gradual return to your pre-disability work, modiﬁed hours, a temporary alternate assignment, or a new assignment. The plan is based on the medical restrictions and limitations provided by your physician. In some cases, you can continue to receive beneﬁts while you are involved in a rehabilitation plan. As the employer, the school board will be part of any return-to-work discussions. You should also make sure the local ETFO ofﬁce is involved.
Appropriate care and treatment
It is crucial to the success of your LTD claim that you are receiving care and treatment from a licensed medical practitioner, continuous from the date of disability. The family physician plays a pivotal role in coordinating your care; however, all LTD policies stipulate that you must be receiving treatment from a medical specialist in the area of the illness. For instance, treatment for mental health conditions must be provided by a psychiatrist or registered psychologist.
Appealing a negative decision
Most insurance companies have an internal appeal process, and there are strict time limits for appealing or initiating a legal action against an insurer. In the event a claim is denied, you may submit new medical evidence as part of an appeal package. You will receive a letter outlining the reasons for the decision and providing direction and guidelines regarding an appeal. Share this letter with your doctor and/or specialist in order to understand what additional information is required.
Unfortunately, teachers are one of the most notorious groups for not reporting workplace accidents/injuries.
They often forego seeking immediate medical attention, opting instead to “tough it out” and hoping the injury will just go away. Some believe that maintaining silence about a workplace accident and just “carrying on” is noble and proves their worth to the employer. Such notions allow the conditions that caused the accident to go unchecked and thus can leave colleagues vulnerable to having a workplace accident as well.
Steps to follow in case of injury
Report any workplace accident/injury promptly to the appropriate school board personnel. In most schools this is the principal. Report all accidents/injuries that occur on the worksite or that arise out of or in the course of employment, no matter how trivial. This includes student injuries. Request that a report be submitted to the WSIB. The key to the success of any WSIB claim is seeking medical attention immediately, or as soon as possible following the accident or injury. Any delay may result in unnecessary delays further down the road.
How to apply for WSIB benefits
There are four ways to initiate a WSIB claim.
The employer completes Form 7, the ofﬁcial accident report, in triplicate. Sometimes this form will be completed at the board ofﬁces and the school will use a general accident reporting form. You have a right to, and should request, a copy of the completed Form 7.
Advise your health care practitioner that the injury was work-related. Your physician must then complete and submit a Form 8 based on his/her examination of you. It is imperative that you report all symptoms to the doctor.
You may also make your own report to the WSIB using Form 6, which the WSIB provides at your request. This form is your opportunity to describe the workplace accident and the injury suffered.
Form 1492C is an alternative way to apply for WSIB beneﬁts and to consent to the release of functional abilities information. However, if you complete Forms 6, 7 and 8 you will not need Form 1492C.
Ensure that you provide consistent information on all of the forms as any inconsistencies – in accident information, dates and areas of injury, and lost time days – will cause long delays in the adjudication of your claim and can even result in it being disallowed.
Functional Abilities form (FAF)
Under WSIB rules every employee injured at work must consent to the release of functional abilities information. This information is used to assess whether you can return to your regular assignment or if you need accommodations. The school board will give you the FAF, which your physician will complete.
Obligation to cooperate and early and safe return to work
The Workplace Safety and Insurance Act sets out a duty of cooperation that obliges injured workers and employers to contact one another as soon as possible after an accident occurs. You and the board must maintain communication throughout the process to ensure your early and safe return to appropriate employment.
The school board must attempt to provide suitable and available employment consistent with your functional abilities. You must assist the school board as required with identifying such work. Contact your ETFO local or a counsellor in Professional Relations Services with any questions or concerns about this process.
Appealing a negative decision
The WSIB system internal appeals process allows you to appeal negative decisions. But there are time limits – you must appeal a return-to-work decision within 30 days. You must appeal all other decisions within six months.
ETFO has established guidelines for helping you when an LTD or WSIB appeal is denied. Depending on the circumstances of your case the provincial ofﬁce may be able to assist you in advancing a claim to arbitration or litigation.
Please contact the LTD/WSIB counsellor-on-duty at 416-962-3836 or 1-888-838-3836 for further information.