Recently in Long Term Disability Category

By David Share L.L.B.

President, Share Lawyers, Lawyers

Many LTD claims are denied or cut-off on the basis that "sedentary work" can be peformed.    Sedentary work is generally defined as follows: exerting (lifting or pushing/pulling) up to 10 pounds of force occasionally (Occasionally: activity or condition exists up to 1/3 of the time) and/or a negligible amount of force frequently (Frequently: activity or condition exists from 1/3 to 2/3 of the time) or lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.

The reference to sedentary work is frequently an oversimplification of the restrictions and limitations people on LTD claims have.    The focus solely on sitting and standing and/or lifting fails to take into consideration the ability to concentrate and focus on the tasks at hand.  Many of the denied LTD claims are for people suffering with "invisible" disabilities where mental health and physical health often collide.

If you have been denied or cut-off because you have been told you can perform sedentary work, you should consult with experienced disability lawyers who can review your circumstances to determine whether you have a viable case to pursue.

By David Share L.L.B.

President, Share Lawyers, Lawyers

Further to our recent blog on "own occupation" and "any occupation" clauses in LTD policies, insurance companies often cite transferrable skills as a reason they have decided they no longer have to pay LTD benefits.

Let's say you have been receiving LTD benefits for a period of time and the insurance company appears to accept that you no longer can do the type of work you used to do.   For instance, you used to do work installing computer networks and systems, which required knowledge of computer networks, but also involved certain physical tasks.     Due to your illness/injury you can no longer handle that type of work, but the insurance company has determined that you could probably handle "sedentary" work.     With, or without the assistance of a vocational assessment, they look at your education and prior experience and decide that you can probably perform a number of alternative jobs that would pay you enough to eliminate any ongoing LTD claim.

Some of the favoured "sedentary" jobs that are noted are, customer service representative, call centre operator, parking lot attendant.....and so on.

Does this mean your claim is over?   No.  Your particular situation should be reviewed by experienced disability lawyers who can challenge the insurance companies decision to cut you off.

By David Share L.L.B.

President, Share Lawyers, Lawyers

Under most group Long Term Disability policies disability payments are made during the initial assessment period if you are unable to perform the essential duties of your "own occupation".    Most often this period is for 24 months (although it differs from one policy to the next).    If you have been receiving LTD benefits and are approaching the end of the Own Occupation period, you may face a termination of your benefits based on the change of definition in what constitutes total disability after the own occupation period expires.

The change of definition is usually referred to as a transition from an "own occupation" definition, to an "any occupation" definition.  Typically this means that in order to qualify for LTD benefits in the any occupation period, you must be totally or substantially disabled from the duties of any occupation for which you have the requisite education, skills or experience.     There are variations on the wording, but this summarizes the typical "Change of Definition".

You may think that it is impossible, or extremely difficult to persuade your insurance company that you qualify for LTD benefits after this change of definition, but you should not give up hope.   With supportive medical evidence, you may have a strong case to fight against the termination of your LTD benefits based on the "Change of Definition".

To find out how, contact Share Lawyers.  We're Focused on Disability Insurance Litigation.

Our lawyers will fight for your disability insurance claim with aggressive legal maneuvering and strategic planning. If you have a long term or partial disability claim, and have been denied benefits, find out what Share Lawyers can do for you.

By David Share L.L.B.

President, Share Lawyers, Lawyers

With some degree of frequency, we see people getting a letter from their disability insurance company saying things like "...as you are no longer disabled, your file has been closed.", or "...as we have denied your claim for disability benefits, your file has now been closed."  Don't make the mistake of simply accepting this statement without seeking advice on whether that can really be true.

The truth about such a statement is that the insurance company would like your file to be closed, and they hope that you simply accept the statement without questioning it.   After all, how can you question or fight a decision made by a large insurance company with unlimited resources?

To find out how, contact Share Lawyers.  We're Focused on Disability Insurance Litigation.

Our lawyers will fight for your disability insurance claim with aggressive legal maneuvering and strategic planning. If you have a long term or partial disability claim, and have been denied benefits, find out what Share Lawyers can do for you.

 

By David Share L.L.B.

President, Share Lawyers, Lawyers

 The next time you see one of those feel-good ads on TV, in a newspaper or on the radio for a insurance company, don't forget that it really is all about the money for insurance companies.   Okay, lawyers work for money too, but we earn it based on the results we get for our clients in pursuing claims against large insurance companies.

A recent case, illustrates just how much money gets thrown around by insurance companies in their efforts to grab further market share.   The Ontario Superior Court released its' decision in Sun Life v. Metropolitan Life, 2010 ONSC 558 (CanLII) on January 22, 2010.   This case is a reminder of the type of stakes involved when one insurer acquires another.   In July, 1998, The Mutual Life Assurance Company of Canada (which changed its' name to Clarica and was then purchased by Sun Life in December 2002), paid $2.2 billion dollars to Metropolitan Life for its' Canadian life insurance related businesses.

The case is about one insurer alleging that they are entitled to further reimbursement or indemnification from liabilities flowing from policies issued by Metropolitan Life prior to its' takeover by Sun Life.    The concern that Sun Life has is that they do not wish to be stuck with the cost of fixing the cost structure of certain policies that Met Life had issued in the past, where their allegations of misrepresentations about the cost of these policies to the end individual policyholders. 

The ins and outs of this particular case will not matter to you if your claim has been denied, be it for long term disability benefits, life insurance or critical illness, but it certainly does reinforce the notion that money really does matter to insurance companies.    Does anything else matter to them?   Absolutely, just nothing matters more than money.

 

 

By David Share L.L.B.

President, Share Lawyers, Lawyers

The recent Ontario Superior Court decision in Campos v. Sun Life, 2009 CanLII 43186 raises once again the complex issue of whether disputes regarding long term disability benefits belong in the Courts or before an Arbitrator.    The case involves a proposed class action for nurse members of the Ontario Nurses' Association, and whether or not retirement benefits under the Canada Pension Plan can be deducted under the long-term disability plan that applied to ONA members entitled to lifetime LTD benefits (a very rare commodity in today's group benefit landscape).

The case invokes the age-old Brown & Beatty analysis which has led to extensive litigation in this area because the analysis must be applied on a case-by-case basis.     In other words, the specific terms of the applicable collective bargaining agreement, as well as the disability plan must be reviewed carefully to come to the appropriate conclusion on the appropriate jurisdiction for a particular case.

In Campos, Justice Lax decided that the subject CBA and insurance plan met branch 4 of the Brown & Beatty approach, namely that the insurance policy was incorporated into the collective agreement, therefore making the claim(s) arbitrable.    She therefore dismissed the claims of the plaintiff in this summary judgment motion.

An appeal seems likely as it seems that the case turned on Justice Lax's interpretation of Article 12.07 from the CBA.   Article 12.07 of the subject CBA states:

Any dispute which may arise concerning a nurse's entitlement to short-term or long-term benefits under HOODIP may (emphasis added) be subject to grievance and arbitration under the provisions of the agreement.

It appears that the word "may" noted above has been interpreted to mean "shall" and has been invoked by the Court to slot this LTD plan into the arbitrable category.   There is no discussion as to why the negotiators of the CBA included the word "may" instead of "shall" and it is respectfully submitted that nurse members of the ONA appear to have a choice between pursuing arbitration or proceeding by way of civil action.

Perhaps the Ontario Court of Appeal will have more to say on this subject, should this case proceed to appeal.   For now, we are left to further puzzle over the appropriate analysis to apply to unionized group benefit disputes.

 

By Kirk Sloane B.A.(Hon), LL.B.

Lawyer, Share Lawyers, Lawyers

Many disability claimants have heard or read about the following scenario: your disability insurer calls you on the phone, sends a representative to your home, or sends a letter proposing a lump sum payment to "buyout" either the future of your disability claim, a disputed portion of unpaid past benefits, or both. In many instances a buyout can be a desirable outcome, but a disability claimant needs to understand the ramifications of such a payment, have confidence that the proposed deal makes sense, and that the proposal is the best available option. Using experienced legal counsel can be an invaluable tool in assessing whether a buyout is the right thing to do and to ensure that the best deal possible is obtained.

 

One of the first considerations for an individual already receiving benefits is to determine the likelihood of the claim being terminated if the buyout proposal is rejected. Some insurers use the fear of a claim termination as a tactic to convince the claimant to accept a reduced amount. If the claim may truly be on the verge of a termination, however, there needs to be an assessment of the potential costs of a lawsuit and the likelihood of winning or losing the lawsuit. Those factors are essential in arriving at a sensible buyout figure.

 

Another important piece of the puzzle is to have a realistic assessment of the nature, extent and potential duration of a claimant's disability in order to make appropriate adjustments to the total future expected disability payments. In addition, a disability claimant needs a thorough understanding of the concept of the "present value" of future benefits in order to calculate the true value of the investment power of a proposed lump sum payment of future benefits.

 

When it comes to a buyout during litigation, the cost and risk factors for further litigation and the potential outcomes are much more prominent factors than in the claim context. In summary, buyout strategies can be complex and it is critical that a disability claimant utilize a lawyer with expertise in dealing with disability claims in order to ensure a satisfactory outcome.

By Leanne Goldstein B.A., LL.B. 

Associate Lawyer, Share Lawyers, Lawyers

 

Employment provides financial sustenance and the ability to contribute to society. For many, their employment forms part of their identity, provides a means for self-expression and fuels self-worth. There are a vast number of individuals who have spent a great deal of their working life employed with the same company. Unfortunately, their loyalty is not always rewarded and sometimes in addition to dealing with the effects of their disability, they are dealing with employment issues at the same time.  

 

It is not uncommon for employers to threaten to terminate employees who are unable to return to work as a result of a disabling physical or psychological condition that prevents them from being able to perform their job duties. These employers send letters to disabled employees threatening to terminate their employment if they do not return to work by a certain date, setting up a "frustration of contract" argument.

 

At common law an employer may terminate an employee who is unable to work due to illness in certain circumstances, on the basis that the employment contract has been "frustrated". In order to succeed in such a case, the employer would need to prove that the employee's incapacity renders further performance of the employment contract impossible.

 

There are, however, certain cases in our courts that have held that the employment relationship cannot be frustrated if an employee is receiving long term disability benefits. The theory behind these decisions appears to be that in providing access to benefits the employer contemplated the possibility of an employee being unable to work at some point. 

 

Our courts have also considered the manner in which a termination or employment takes place. Employers are required to treat employees with good faith and even handedness at the time of their termination. Given that employees with disabilities are often more vulnerable to experiencing psychological distress, this issue becomes particularly pertinent.

In Wallace v. United Grain Growers Ltd., [1997] 3 S.C.R. 701, a 59-year-old employee was dismissed without explanation after fourteen years as a top salesperson. The manner of his dismissal led to him suffering from depression. Courts have relied on this decision to review the employer's conduct during termination. Where employers have for instance been dishonest and misleading with an employee, made unfounded allegations against an employee, withheld money from an employee and embarrassed an employee, the courts have considered this conduct in awarding damages.

The Human Rights Code provides a measure of protection to employees from discrimination on the basis of disability. An employer is required to offer a disabled employee accommodation in the form of modified employment (to the point of hardship for the employer) that would facilitate the employee's ability to perform their job. An employee who is dismissed as a result of being unable to work due to a disability may be able to make a Human Rights complaint against the company.  

 

Sometimes an employer terminates employment before an employee is able to make a claim for disability benefits, leaving the employee open to coverage issues should the employee attempt to make a claim for disability benefits after their employment has been terminated. Our courts have in certain situations found employers liable for providing disability benefits to employees terminated before or while they experienced a disability (see for instance: Re Stelco Inc. (2005 Ont. S.C.J.): Zorn-Smith v. Bank of Montreal (2003 Ont. S.C.J.): Prinzo v. Baycrest Centre for Geriatric Care (2002 Ont. C.A.): Keays v. Honda Inc. (2005 Ont. S.C.J.).

  

In certain circumstances, employers provide disabled employees with a termination letter together with a severance offer suggesting that they are complying with their legal requirements. Many employees are unaware that statutory termination and severance pay are minimum legal requirements. Employees often believe that the employment standards payout is the maximum that they can receive. However, depending on the circumstances of a case the true value may be greater than the proposed offer based on common law damages. Often employees are forced to attend meetings and sign documents in which they give up their rights to pursue employment issues.

 

It is important to know and understand your legal rights at all times. Consulting with a lawyer familiar with the interplay between disability and dismissal is essential to ensure that your legal rights are protected.

 

By Janice Grevler  B.A., L.L.B.

Associate Lawyer, Share Lawyers, Lawyers

 

There's no doubt that internet-based social networking has shrunk the world in which we live, and has allowed us to stay connected with others, near and far.  These social utilities provide a plethora of otherwise-unavailable information to keep our "friends" (real or web-based) informed of our whereabouts, our activities and, even, our daily status. 

 

Yet the benefits of staying "connected" can have drawbacks when the information attainable on the world-wide web is used for more than social networking and is, instead, utilized for the purposes of defending a personal injury or insurance lawsuit.

 

Those who have profiles on Facebook, MySpace, Twitter or other social networks, and who are involved in litigation, should be forewarned that insurance companies too have begun to employ the internet for their own benefit.  We have witnessed this phenomenon over the past many months.   On the basis of information obtained on social networking utilities, we have seen defence counsel argue that various Plaintiffs in personal injury or disability actions are not as disabled or injured as they have claimed.  What may seem to be a harmless comment to update one's "status" on Twitter or Facebook, or to communicate with a friend on his or her Facebook wall, may ultimately be used against the author where he or she is involved in litigation.  While investigations of the Plaintiff (including surveillance) have long-since been used by Defence counsel and insurance companies alike, these tactics are now incorporating searches on various social networks to look for clues about the Plaintiff's day-to-day life.  At its worst, any such "clues" may be taken out of context by a Defendant who seeks to portray a seemingly harmless comment or photograph in an unfavourable light to the detriment of the Plaintiff's claim.

 

To eliminate or minimize the risks that a Plaintiff will encounter in the course of litigation, he or she should keep in mind the following tips related to social networking:

 

  1. Consider removing your Profiles from social-utility networks pending the outcome of your litigation.  If you are not prepared to do so, know that information about you on these sites may be used against you;

 

  1. Ensure that you employ the maximum privacy settings possible, including not allowing others to view your friends list on Facebook,  so as to limit the access that outsiders have to information about you;

 

  1. Be aware that, on Facebook, even where your settings are "private", non-friends may still gain access to information about you by reviewing the profiles, photographs and walls of your friends (especially those whose settings are less "private") for information that may pertain to you.  Investigators will endeavour to retrieve information about you by accessing your friends' profiles;

 

  1. Be wary of photographs and videos that you upload to your Facebook or MySpace profile, as well as your friends' photographs on which you are "tagged".  A picture is worth a thousand words and may be used by a Defendant, out of context, to undermine your personal injury or disability case.  Untag yourself on photographs posted by others, or ask your friends to remove photographs of you that could be used against you.  Know that a friend who is "tagged" in your photo album will, in turn, provide his or her friends with access to your album, unless the strictest of privacy settings is selected;

 

  1. Keep in mind that every time you make a comment on Facebook, whether it be on someone's wall or photograph or as part of a group, your note may be easily accessible to investigators.  Keep such postings to a minimum and be cautious about commenting on anything that you would not like raised in the course of your lawsuit;

 

  1. Similarly, investigators can easily ascertain to what "Events" you have accepted invitations over Facebook (whether they be social, recreational or other events), thereby becoming informed of your activities and social calendar.  Keep this in mind;

 

  1. As tempting as it may be to change your Status on Facebook or Twitter regularly to reflect the goings-on in your life, we recommend that you not do so.  Through a personal injury lawsuit, it is optimal for the Plaintiff's lawyer to control, or at least be aware of, information about the Plaintiff's daily life that is provided to the Defendant.  The Plaintiff's lawyer will not be aware of, and won't have control over, information gleaned from Facebook or Twitter Status Updates.  A seemingly benign Status Update, for example, such as "Peter had a great time with his friends at the park today", can be used to undermine a Plaintiff's claim that he has lost enjoyment of life owing to an accident.  The Status Update, of course, does not indicate for how long Peter was out at the Park, how much pain medication he ingested that day, whether he required assistance with transportation to and mobility at the park, whether his outing caused an exacerbation in his symptoms thereafter and whether this is the first time Peter has socialized since the accident.  Taken out of context, therefore, the comment can have consequences for Peter in the course of his lawsuit.

 

So, in short, what can you take from all of this?  Be cognizant of the information you are sharing with anyone on-line, even where it appears that you have control over the reader.  Think before you speak on social networks.  Only say or reveal information that you are amenable to sharing in the course of your lawsuit.  And, definitely, speak to your lawyer if you have any question about how your participation on social networking utilities can impact on your case.

By David Share L.L.B.

President, Share Lawyers, Lawyers

Over the past several years a large number of Critical Illness Insurance policies have been sold to Canadians either through private policies sold directly to them, or through group policies provided through employers or associations.    These policies are designed to pay a one-time lump sum benefit to an individual suffering from an illness set out within the policy.    The great misconception that members of the public have regarding these policies is that the benefit is paid out on the simple confirmation of the diagnosis of one of the listed illnesses.   

While payment may frequently be made without a significant fight with the insurer, rejection of such claims appears to be on the rise.   Claim denials are based on a number of potential factors, but we are seeing denials based on two principal areas:  1) The illness diagnosed does not appear to meet the criteria as defined in the policy; and 2) An allegation regarding a negligent or fraudulent misrepresentation regarding the individual's health status at the time the policy was applied for. 

If your claim for payment under a Critical Illness policy has been declined, you should contact a lawyer to discuss the possibility of challenging these decisions.   Our firm has years of experience in dealing with disputed insurance claims.  Familiarity with policy wording and underwriting requirements is crucial if you are to have any chance of success in disputing a claim rejection.

About this Archive

This page is an archive of recent entries in the Long Term Disability category.

Long Term Care Insurance is the previous category.

Mediation is the next category.

Find recent content on the main index or look in the archives to find all content.