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Short-term and long-term disability benefits: The process

Brenda Hockley, Sunlife Financial

Ms. Brenda Hockley is Manager, Health Management Services, Group Disability Western Region with Sun Life Financial. She received her BSc. (Honours) in Kinesiology from the University of Waterloo in 1986. At The Canadian Back Institute, she grew the company from one to fourteen clinics. In 1992 she entered the field of vocational rehabilitation and served the short- and long-term disability-insurance communities in Ontario and BC with Crawford Canada. She then moved to RBC Insurance in the short- and long-term disability markets. Ms. Hockley is on the Board of Directors of the Vocational Rehabilitation Association of BC and is a Registered Rehabilitation Professional and Certified Vocational Consultant.

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Ms. Melanie Dufour

Melanie Dufour is Disability Manager at Sun Life Financial, Melanie is responsible for overseeing the day-to-day management of Short term disability and long term disability absences, Melanie has knowledge of disability operations and insurance terminology, including adherence to any special requirements of group and or individual insurance policy. She is also responsible for ensuring consistent execution of our disability best practices and processes, processing claims through a team of Abilities Case Manager, implementing and reviewing Return to Work plans and many more aspects of Disability. Melanie has 6 years’ experience in managing group benefit employees, Melanie is also an expert in Client Experience Management expert. She has lead large teams of customer service group for large clients. Melanie studied Psychology at Concordia University and uses her experience to help with claims of mental health nature.

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Disability benefits

Most short-term disability plans provide coverage for 8 to 52 weeks. Once the insurance company approves a claim it will be regularly reviewed. The insurer will ask the patient’s medical team about the next steps for treatment and will regularly phone the patient for updates. The goal in this period is for the patient to return to work in their own occupation with or without accommodations. If the patient’s medical team states that the patient is unable to return to work during this period and the patient has a long-term disability plan, the patient can apply for benefits under it.

The long-term disability plan may have a clause covering pre-existing conditions. A pre-existing condition is any condition for which the patient has already received medical advice or treatment a typically year prior to enrollment in a new insurance plan.

Most long-term disability plans have periods that cover whether the patient can return to their own occupation or any occupation. To receive disability benefits during the own-occupation period, the patient must be totally unable to perform any and all aspects of their current occupation. This period depends on the insurance contract and can vary. The most common period of own occupation is 2 years. During this time, the patient’s case manager at the insurance company gathers information about their ability to perform their own occupation.

When the own-occupation period ends, the any-occupation period begins. The patient’s case manager will review their ability to perform any occupation that:

  • the patient has acquired skills and qualifications for
  • does not compromise the functional restrictions and limitations that the patient’s doctor says prevent returning to work in their own occupation
  • provides an income similar to the one the patient had before going on disability

Regular updates required

Once the patient’s claim for long-term disability benefits is approved, the case manager will ask for regular updates on:

  • treatments planned for the patient
  • the patient’s ability to do activities of daily living
  • non-medical factors that influence the patient’s time off work (for example, parent or child care, moving to another home)
  • the patient’s occupational requirements
  • situations at the patient’s workplace that can cause the patient stress (for example, lack of workplace supports, poor performance before the patient’s cancer diagnosis, job restructuring)
  • the openness of patient and their employer to modified work while the patient is on disability
  • the benefits of providing supports for returning to work (for example, tests, assessments, vocational rehabilitation)

The case manager may ask for assessments by healthcare professionals, who will provide these updates. Based on these assessments the insurance company may fund services to help the patient return to work.

Help with getting back to work

Case managers from the insurance company may have access to vocational rehabilitation consultants. These professionals work together with the patient’s case manager to improve the patient’s health and facilitate their successful transition back to work. The professionals do this by:

  • identifying and confirming factors that may slow the patient’s recovery
  • developing a health management plan to resolve, or mitigate, the identified factors so that the patient can eventually prepare to go back to work
  • working with the patient’s employer to put in place any job accommodations or modifications the patient may need
  • developing a graduated return to work plan with the patient’s employer

If the patient cannot return to their own occupation, the case manager and vocational rehabilitation consultant will help the patient return to work in a different occupation by identifying the skills and training the patient need for that occupation.

The vocational rehabilitation consultant creates a vocational rehabilitation plan for the patient. To create this plan, the consultant gathers information about the patient’s circumstances to decide which goal is best suited to getting the patient back to meaningful employment. The consultant starts with the first goal on the following list and works down through the list to find the most feasible goal:

  • Returning the patient to the same work with the same employer
  • Returning the patient to the same (modified) work with the same employer
  • Returning the patient to different work with the same employer
  • Returning the patient to similar work with a different employer
  • Returning the patient to different work with a different employer
  • Re-training and/or re-educating the patient for a different occupation that does not compromise their functional restrictions and limitations

The patient’s case manager will also help the patient get ready to return to work, when it is possible based on their restrictions and limitations. If the patient is returning to work gradually the patient’s case manager will help calculate a top-up to the patient’s employment earnings and complement them with disability benefits. There may be times after the patient returns to work that they need to go on disability again (for example, chemotherapy or surgery). While waiting, though, the insurance company will expect the patient to work. The case manager will help the patient to return to work between maintenance treatments or while waiting for medical procedures.