Disability Insurance: Information for PSAC Members

A “Total disability” means that you are totally disabled from working.

General Meaning

1. You can’t do your job (the first 24 months)

You must be in a continuous state of incapacity due to illness which continues during the Elimination Period (13 weeks or the expiry of your accumulated sick leave credits, whichever is later) and the following 24 months, and prevents you from performing all duties of your regular occupation or employment.

Note:

If you are required to use your driver’s license in your job duties, and you lose your license, or it is suspended, because of illness (unrelated to alcoholism or drug addiction) you are considered to be totally disabled during the elimination period and the following 24 months, but only while such license continues to be withheld for the same reason.

2. You can’t do an alternative job (after 24 months)

While it (a state of incapacity) continues thereafter, prevents the employee from engaging in any commensurate occupation for which he/she is or becomes reasonably qualified by education, training or experience.

3. You must be under active care of a medical doctor

In no event, however, will an employee be considered Totally Disabled if during any period he/she does not take part cooperate in a reasonable and customary treatment program.

 You will not be paid disability benefits if:

  •   the total disability resulted from self-inflicted injuries, attempted suicide, commission of a criminal offence, war (unless exposed to it by the performance of your duties as directed by your employer), active duty with any armed forces (including civilian noncombatant units serving in such forces), or participation in a riot, civil commotion or insurrection.
  • Under certain conditions, if you have a pre-existing condition.  During the first year of your coverage under the DI plan, you may experience a worsening of a condition that you had when hired. If this preexisting condition results in total disability, you will only get DI benefits if: .   You had a consecutive 13 week period when you did not need medical attention for that condition.  AND . You were not absent from work for more than two full days. Unless you meet both conditions, your claim will not be paid. This restriction no longer applies after your first year. It does not apply to any other disabling condition that is unrelated to your pre-existing condition.

For the first 24 months, as long as you are disabled from working in your own job.  After 24 months, DI plan members will continue being paid benefits when they can provide medical proof that their disabling condition prevents them from doing a “commensurate occupation” for which they are reasonably qualified by education, training or experience.

According to the DI policy, “commensurate occupation” means a job for which the rate of pay is not less than 66 2/3% of the current salary for your regular job.

What about rehabilitation programs?

Sometimes your health situation may enable you to participate in a rehabilitation program, which means re-training or new work. Normally you must request approval in writing from Sun Life during the first 24 months that you receive benefits. If you have received DI benefits for more than 24 months, ask Sun Life’s Rehabilitation Unit for counselling and help.

Always be clear that you are ready to participate in any program that respects your medical limitations. You have options like gradual return to work (for example - half days for the first month), or doing some but not all tasks. No one wants to make you sick again. On the other hand, you may be cut off benefits if you do not cooperate.

What about rehabilitative employment?

The DI plan provides an opportunity for you to participate in rehabilitative employment. Every case is different, but the odds of going back to your old job drop after two years. Wages from any job you get through rehab are not cut from your DI payment. You can keep the extra money—unless your DI plus wages add up to more than your old job.

To get you back to a suitable job, a special payment of up to three times your net monthly DI benefit may be made for training programs, visual aids, special equipment or whatever meets your medical needs. They can even go higher, but then it needs Treasury Board approval.

The plan also allows Sun Life to motivate and encourage workers with disabilities to continue working after their rehabilitation benefits would normally run out. Rehab will help you get back to work. You should cooperate with their plans, as long as they respect your medical limitations.

See Question 12 for more information on accommodation if you plan to go back to work.

If you satisfy Sun Life's medical consultants that you meet the definition of total disability in the DI policy, you are eligible for DI benefits up to age 65. Again you will need concrete and convincing medical evidence.

Sun Life will stop paying benefits if and when your medical situation improves and you no longer fit the DI plan's definition of "total disability".

Report disability to your HR office without delay and follow up frequently.  You, your doctor and medical specialists know best whether your health problem will result in a condition that prevents you from performing the regular duties of your own occupation. You should inform your HR Office immediately and start proceedings regarding your DI application in order to avoid frustrating delays. If necessary, you can download the application from the Treasury Board Web site

An application for Canada/Quebec Pension Plan disability benefits and Workers' Compensation benefits may also be made at the same time, since the DI plan policy gives the insurer (Sun Life) the right to reduce the amount of the employee's monthly DI indemnity benefit according to their estimate of other disability income under these programs and others.

When you apply for CPP or QPP, you may be asked to sign an "offset agreement". It is all right to sign these. You are applying for a number of income support schemes. It is not intended that you apply for several and that they add up to more than your original salary. It is intended that you start getting at least partial income as soon as possible. This even applies where there is a lawsuit. If you successfully sue somebody for causing a disability that Sun Life was paying you for, then a portion of your award would be turned over to Sun Life.

Departmental HR personnel are trained and experienced both in processing DI claims and providing counseling and advice to employees on all aspects of the Disability Insurance Plan, Workers' Compensation, CPP/QPP, the Public Service Pension plan and related matters. They can explain how much you will get from each of these sources. See also question 12 and 13. Discuss any problems with your union representative.

It is important to follow up with HR when a DI claim is filed and you are uncertain about the status of your case. 

Remember that while the provisions of the DI plan were developed in consultation with the unions concerned, your direct link to Sun Life is the HR office in your employing department or agency.

 

Processing and approval of your DI claim takes time. Be prepared for delays.  When your DI benefits have been approved, payments start either:

  • After your paid sick leave or injury-on-duty leave expires; or if these payments last less than 13 weeks;
  • After 13 weeks of disability (the “elimination period”).

The 13 weeks does not need to be continuous. It may, under certain circumstances, be accumulated for the same disability over a period of one year.

An elimination period (sometimes called a waiting period) is normal in long term disability plans. Do not wait until the "elimination period" is over. Apply for DI benefits as soon as you have reason to believe your time off work will be longer than the elimination period. You may qualify for employment insurance benefits during the elimination period.

You may have enough sick leave to cover the elimination period. You may also be covered by a combination of sick leave and EI benefits. On the other hand, even after the 13 weeks, you may still be caught up in establishing your right to either DI or workers’ compensation. If you are still waiting and have no income, approach Social Services (normally administered by your municipality) to tide you over.

If the disability is work-related and you find yourself in a situation of financial hardship, you can approach your HR, who will bring the matter to Sun Life's attention.

When Sun Life is approached by an HR office concerned about an employee's situation of financial hardship, they can arrange benefits. You may have to apply for these emergency benefits because appealing a Workers’ Compensation decision is often a slow process. Don’t wait. Call your union representative if you need help.

You will be are required to sign a statement agreeing that you will continue to pursue your Workers’ Compensation claim up to and including the final level of appeal. Following any payment the Workers' Compensation Board will first reimburse Sun Life for the benefits paid to you.

It is always prudent to save for rainy days when all is going well, and thereby reduce the shock of potential financial hardship when things are not going well. Easy to say, not easy to do. But when you get a contract settlement, an overtime cheque, etc. stash some away. You may also look into the possibility of deferring loan or mortgage payments if you are still without income. You are safer to discuss it first than just miss a payment.

Get the paperwork right .One of the most frequent reasons for claim rejection is that medical documentation given to Sun Life by claimants and medical professionals isincomplete. 

It is important to include, with your DI application, a report that outlines in detail the medical reasons why you cannot perform the regular duties of your occupation. The report should show the type and duration of therapy being given, medication prescribed, frequency of treatment, results of tests, hospital records, consultation notes, etc. Be sure to include documentation from all medical professionals, including specialists, who are treating you.

Your union representative will be able to provide you with a model letter to your doctor(s) which will help you get accurate and complete information.

To establish and support your claim, the report should be as complete and convincing as possible. You should ensure that the medical professionals completing the medical reports have outlined your disabling condition within the DI plan's definition of "total disability" . The same applies when, towards the end of the first 24 months of disability, Sun Life requests medical proof to show that the disabling condition continues. Sun Life will want evidence that you are unable to perform the duties of even a "commensurate occupation". A vague description, for example one which states thatyou , while disabled, can still perform "light" duties, could mislead the insurer, cause delays and possiblya denial of benefits.

 Medical professionals should be particularly cautious in reporting on situations of psychological impairment. Any indication that such impairment might be work-related may lead to a denial of the DI claim by Sun Life, and result in a lengthy and frustrating process of having to apply for Workers' Compensation, again with the possibility of denial and subsequent time consuming appeals.

Your claim is first processed by a claims adjuster at Sun Life. If the information you give is not sufficient to enable Sun Life to make a decision on the claim, they will request more specific and detailed information. Keep copies of everything you send them. If you give sufficient evidence, the claim is approved. If not, the claim is denied.

If your claim is denied, Sun Life will ask you for more documentation. If, after another review, the claim is still refused and you disagree with that decision, you can ask Sun Life's Disability Management Unit to review your case. This committee, made up of senior claims analysts, may overturn a claims adjuster's earlier decision.

To appeal, send a letter to:

Disability Management Unit
Group Claims Control Department
Sun Life Assurance Company of Canada
PO Box 12500, Station CV
Montreal, Quebec H3C 5T6

Visit their website for phone numbers and other contact information.

You can also give your letter to Human Resources, or ask your PSAC Component or Regional Office to handle your appeal. Don’t forget to show your social insurance number on your letter and on all documents you submit.

After you appeal:

Sun Life will tell you what documents you need to qualify, and will respond on a priority basis to questions from HR about the status of your appeal. In emergency situations, Sun Life will usually answer direct questions from you or your representative.

Have your certificate and control numbers handy.

If your appeal is rejected, here’s what to do:

If your case is well-substantiated, the Public Service Alliance of Canada will refer your case to the Disability Insurance Plan Board of Management. You’ll need to give your Component or Regional Office complete medical information, a brief chronological description of events, and a signed form alled Authorization for Release of Information. This form authorizes the insurer to release all necessary confidential information to the Board, including medical reports which Sun Life has at its disposal. The form is available at Human Resources, Public Service Alliance of Canada Components and Regional Offices.

Officers of Public Service Alliance of Canada Components and Regional Representatives will give you advice in developing your submission to the Board and will then submit a request with all relevant documentation to Public Service Alliance of Canada headquarters (Programs Section). The Public Service Alliance of Canada will then refer the case to the Board of Management. This is the best procedure to follow.

Individual cases can also be submitted to the Disability Insurance Plan Board of Management directly by you, by Public Service Alliance of Canada Components and Regional Offices by or through your employing department or agency to:

Committee Advisor
Disability Insurance Plan Board of Management
National Joint Council
P.O. Box 1525, Station "B"
Ottawa, ON K1P 5V2

The Disability Insurance Plan Board of Management reviews cases referred to it on a "blind" basis. This means that your case is not identified by your name, but by a number. This ensures an objective review of all relevant factors which determine your eligibility for benefits. The Board may ask you or Sun Life for additional medical examinations and reports, or for other information which the committee needs for its decision. Because of this, the process may take several months to complete.

You, your department or agency, Sun Life, and the Public Service Alliance of Canada, among others, are informed about the Board’s decision as to whether the insurer acted within the intent of the DI policy.

Most of the critical issues about your claim are challenged through the procedure above. There may be some administrative issues that would have to be resolved by a grievance. An example would be if your employer deducted the wrong amount of premiums. Since they made that mistake, not Sun Life, you would have to ask your employer to correct it. If they will not correct it voluntarily, the grievance procedure is the correct legal mechanism. There are time limits to filing grievances, so raise the issue with your union rep when you become aware of it.

This grievance procedure does not apply to decisions made by Sun Life concerning adjudication of DI claims, or the evaluation of declarations of insurability submitted to Sun Life in connection with late applications for membership. These are subject to review by the Disability Insurance Plan Board of Management, as described earlier.

What about legal action?

If all other options fail, you may consider legal action. In view of the complexities and usually large legal costs involved, Public Service Alliance of Canada members are advised to consult with their Components and Regional Offices and through them with the Public Service Alliance of Canada headquarters about the prospects of successful court action. Legal costs are your responsibility, unless prior approval of legal action is requested by Components and approved by the Public Service Alliance of Canada Executive Committee.

Public Service Alliance of Canada
Membership Programs Branch
901-233 Gilmour Street
Ottawa ON K2P 0P1
(613) 560-4200
1 888 604 PSAC (7722)

PSAC Employment Equity 

PSAC Duty to Accommodate

Coughlin and Associates
PSAC Insurance Trust
PO Box 3518, Station C,
Ottawa ON K1Y 4H5
(Tel.) 1-800-216-1107 (Fax) 613-231-2345
psacforlife@coughlin.ca

Sun Life Assurance Company of Canada
Disability Management Unit
Group Claims Control Department
PO Box 12500, Station CV
Montreal QC H3C 5T6
(Tel.) 1-800-361-5875 (Fax) 514-954-1219

Disability Insurance Plan Board of Management
National Joint Council
Committee Advisor
P.O. Box 1525, Station B
Ottawa, ON K1P 5V2

Treasury Board of Canada Secretariat

Canadian Human Rights Commission

Canada Pension Plan Disability

The Canadian Council on Rehabilitation and Work

Office for Disability Issues - Human Resources Development Canada