Own Occupation vs. Any Occupation: What Happens at 24 Months and How to Prepare

Over the past couple of years, you’ve been fighting a battle with yourself, wrestling with your own emotions, struggling to come to a point of accepting a future so different from the one you’d always envisioned for yourself. You had been thought of by friends and co-workers as a fearless leader. Now, your career and team sports activities have been ground to a halt. Forced to rely on disability benefits, your life has been dramatically changed for the worse. In the beginning, enduring the unrelenting medical exams, interviews, and therapy sessions, you’d held on to the hope that the doctors and therapists would be able to “put you back together”. Over the past months, you’ve been forced to come to grips with the fact that your former lifestyle is a thing of the past.

Even as you had been struggling to find meaning and purpose in this forced sedentary existence, the letter you just received means your problems are just beginning; the financial support on which you’ve been forced to rely is going to end. You received written notification that your disability benefits are going to be cut off at the two-year mark coming up at the end of this calendar quarter due to the 24-month “change of definition”.

For the second time since this nightmare began, you feel utterly blindsided. The language in the letter is hard to understand — you’ve tried to follow all the steps and comply with all the requirements …Is there nothing you can do to protect your benefits?

What is the 24-month Change of Definition?

Every LTD policy has a definition of disability, meaning what conditions must exist for the insured to collect the benefit. In most Canadian LTD policies, that definition changes after the insured has collected benefits for two years.

1. The OWN OCCUPATION definition of disability:

You are unable to perform the duties of your own occupation. This definition applies for the first two years, starting from the month benefits begin.

2. The ANY OCCUPATION definition of disability:

Starting from the COD (change of definition date), you are entitled to receive benefits only if it is proven that you are unable to work at any occupation for which you qualify based on your level of education, training, and work experience.

Own Occupation vs Any Occupation at a glance:

Why is my LTD insurance company sending me this letter?

The 24-month change of definition is part of your LTD insurance contract. By sending you the change of definition notification letter in advance, the company is complying with the requirement to give you some time to prepare a response and to gather updated medical evidence.

On the other hand, it is important for you to understand one thing: it is generally not in the best interest of any insurance company to help you. It’s a simple matter of cost control. While they must honor the policy contract they’ve issued to pay legitimate disability claims, the company is in business, and minimizing disability insurance payouts helps increase their bottom line. Read more about What Insurance Companies Don’t Want You to Know.

What is the “any occupation” definition of disability going to mean for me?

The “bottom line” is this –If the insurance company decides you no longer are “disabled enough” to meet the new standard, they may stop paying your Long-Term Disability benefits. That very well might happen — even if you are truly unable to work full-time.

1. You are going to have to “re-prove your case”. Reasons often cited by Ontario LTD insurance companies for discontinuing benefits at the 24-month mark include:

• Insufficient medical proof – there hasn’t been enough objective evidence that you are unable to perform  “any occupation” duties
• Refusal of treatment – you have not followed a recommended treatment of rehabilitation plan
• Surveillance findings – your level of activity contradicts your claim of disability.

2. You will need to undergo new tests and evaluations:

FCL (Functional Capacity Limitations) tests the impact your physical or mental condition has on your ability to work, not the details of the condition itself.

FCE  (Functional Capacity Evaluation)  is performed by an occupational therapist or physiotherapist to test the extent you are now able to lift, pull, push, and perform repetitive actions, or whether further rehabilitation is likely to improve your capacity.

IME (Independent Medical Examination) conducted by doctors and therapists chosen by the insurance company to evaluate your condition and decide if the treatments recommended by your own doctors are necessary and appropriate.

TSA (Transferable Skills Analysis) assessing your “history” of work experience, education and training to decide if you qualify for gainful employment.

Competitive Employability Assessment – judges whether, given your now diminished physical and mental capacity, employers will want to hire you for any job paying a reasonable wage

Note: It is not unusual for the insurance company to require that you cover part or all of the costs of the evaluations.

Where to turn? What to do next? You’ve just received a 24-month termination of benefits from your Ontario LTD insurance company — it’s crunch time…

In the termination of benefits letter, the insurance company offered you the right to appeal their decision to stop paying LTD benefits. They were required to do just that. The unpleasant truth, however, is that all those vocational experts, medical doctors, therapists, and investigators they’ve hired to re-evaluate your situation are far more likely to side with them than with you. And there’s a deadline looming…

Should you take the insurance company’s offer to allow you to file an “internal appeal”?

How can you possibly have time to undergo all those new medical and vocational exams and interviews within the 180-day deadline? How will you compile new evidence of disability? Will every doctor who treated you in the past answer your request for new, more complete information?  While benefit payments are suspended, how will you survive financially, much less pay for new evaluations and testing? You’re going to need help — now.