1)Introduction. This chapter covers hints for dealing with insurance companies, reassessments, C.P.P. disability insurance and how to avoid some of the problems other people have had to face. 2)** Resources for insurance claims #94023-9 3)** Magnitude for insurance companies. At the Physical Medicine Research Foundation Conference held in Vancouver on May,1994, Dr. Cameroon, Medical Director for London Life Insurance, discussed long-term disability claims, comparing M.E., F.M., and R.S.I. (Repetitive Strain Injuries).
TYPE OF CLAIM (figures as of 1994) |
M.E. |
F.M. |
R.S.I. |
# of claims |
78 |
224 |
149 |
% of total long term disability payout |
1% |
2.8% |
1.9% |
% males |
18 |
20 |
70 |
% females |
82 |
80 |
30 |
Mean age |
43 |
52 |
56 |
Average duration (months of claim) |
37 |
45 |
49 |
Annual projected cost in millions (London Life) |
$1.3 |
$2.2 |
$1.5 |
Total industry cost of claims |
$27 |
$46 |
$30 |
** Note: London Life carries approximately 5% of the Canadian share of long-term disability claims. 4)Life Insurance. Most life insurance companies will not pay an insurance claim for suicide within two years of you purchasing the policy. Most life insurance companies require a modest medical history, sometimes a blood test. Approximate cost for term life insurance is $30 per month for $250,000 for a 30 year old male. When you make your application, present the truth, but only in a way that benefits you. Do not lie, because they can then cancel the policy and not pay your beneficiary. Ensure that you have adequate coverage early on in the illness. a)** Life insurance policies. Some insurance companies will pay your premiums while you are disabled. Check your policy to see whether you have the disability option; if you don't, try to add it on. b)** Healthy family member insurance coverage. Since M.E. may be contagious in the first six months, ensure that other family members are covered with life and disability insurance and on personal loans or mortgages. This prevents two people from being sick without coverage. If the healthy family member becomes sick with any type of illness, you need that extra protection even more. 5)** Mortgage insurance policies. When you applied for your mortgage, you may have applied for mortgage insurance. Check to see whether you have a disability benefit, so that your mortgage payments are made by the insurance company while you are ill. If you don't have this insurance, see if you can add it on. If you carry this insurance, your monthly payments will be made during the term of your disability. 6)** Car loan, or other personal loan. You may have disability insurance coverage on your personal loans - if not, see whether you can add it on. a)Financial institutions will consider your C.P.P. benefits (including your children's portion) when you apply for a loan, as long as they feel confident that you will be receiving these funds for the foreseeable future. 7)** U.I.C. provides up to 15 weeks of sick benefits, but they must fall within your one-year U.I.C. claim. Your doctor must fill out a special form in order for you to receive this benefit. If you have filled in U.I.C. claim forms saying that you have been willing and able to work, when in reality you were too sick to work, you can make a "voluntary disclosure" (by phone) to tell U.I.C. that you have incorrectly filled in previous report cards. This might prevent U.I.C. from assessing you a penalty because you did not tell the truth. 8) ** Help with insurance problems - who to contact: a)The Insurance Bureau of Canada, Phone #1-800-609-6552; b)** Send a copy of your insurance report to The Insurance Inspector for the Government if you have been having problems; c)The Canadian Life and Health Insurance Association (CLHIA) #94017-1 has a free booklet "Where Will The Money Come From If You're Disabled?" Counsellors are available for insurance and disability advice Phone #1- 800-268-8099. d)The National M.E./F.M. Action Network has people specializing in helping those with insurance problems. Lydia Nielson (#613) 829-6667) is in touch with lawyers who will handle M.E. or F.M. cases. e) M.E. Canada has a fulltime legal aid staff member who will help you and/or your lawyer. f)The Insurance Council of B.C. is located at #225-701 West Georgia, Vancouver, B.C. V7Y 1C6 (phone #688-0321). g)** The Insurance Institution Commission with the Superintendent of Insurance. Phone #660-2947/ fax 660-3170. 9)** Harassment by an insurance company. If you are being harassed with phone calls by your insurance company, make sure you take the upper hand in the conversation. The first thing to say is "Just a minute while I get my tape recorder" (It is legal to tape-record a conversation as long as the other person is aware that this is being done.) Ask his name, address, title, supervisor's name, date and time. If you do not have a recorder, take good notes. Follow up the conversation with a letter to the insurance company, detailing and confirming what was discussed. This letter then becomes a legally binding document if the company accepts it. Learn the techniques used by insurance companies to your advantage. 10)** Disability Insurance. a)** Private disability insurance. There are very few insurance companies that give private disability insurance. If you have short term/long term disability through work, make use of it. It is there for your benefit. It is much harder to get compensation once your employment is terminated than it is to take the disability now. {PO}{It is better to be on disability and worry about what your employer thinks later; don't leave yourself high and dry.} b)** Agenda for short and long-term disability. The normal procedure for most companies is to put you on short-term disability for 3 - 6 months; you then have to fill out more forms to go on long-term disability. The insurance company will then cover you for at least a year. At that time, most insurance companies will insist that you apply for C.P.P. disability benefits. During the 2nd year , they will usually require you to see one of their "independent specialists" (usually a psychiatrist). At this point, they will try to disqualify you from receiving further benefits by stating that you have a psychological disorder, or are not sick. If you have passed this obstacle, it gets harder and harder each year to continue to receive benefits. {PO}{It is rare for someone to be on long-term disability benefits longer than 3 years. From my experience, I would estimate 90% - 95% of M.E. and F.M. patients still eligible for long-term disability have been denied further benefits sometime during the 2nd or 3rd year of their claim.} (1)** Several insurance policies state that they will not cover you longer than 1 or 2 years if you have a depressive illness. It is very important that you do not use "depression" as your main disability, or you may be terminated from receiving benefits. (2)** Some insurance policies state that they must prove that you are capable of doing the job that they suggest you can do. c)** Check your insurance policy. Read your short and long-term policy carefully, and follow the requirements so that you are aware of your rights, avoiding such things as cut-off or expiry dates. This will also make you aware of your company's obligations - in some instances employers state in the contract that they will keep your job open for 1 year, and after that they can give you any job with the company. Ensure you look at the detailed contract, not the abbreviated form some employers and unions give to new employees. The shortened version may have important details left out. (1)** Policy deadlines. Many long-term disability and insurance contracts have deadlines for you to make a claim. Some of them are as short as 6 months, or 1 year. You do not have to be diagnosed with a specific illness to make a claim, you only need to be unable to work. Read your policy thoroughly. If you have a group policy, you will not usually get a copy of the actual contract, but just a summary. Obtain a copy of the full policy from your employer, or get something in writing stating any deadlines. (2)** Policies and government regulations change. Keep up-to-date on any policy changes that might affect you. d)** Your employer is not obligated to keep any position open for you longer than 6 months while you are on long-term disability. In some cases, long-term disability claims can continue for many years, even if your job is terminated. e)** What job will be kept for me? #940901-1 The Supreme Court of Canada has made several rulings with regard to the type of job you can expect to return to when your health improves. Several long-term disability insurance policies state that your job will be held for one year. After that time, your employer (or the government) cannot ask you to take a job that is a in a lower position or pay, eg you are not expected to go from an executive position to a "McDonald's employee" position. f) If you move while you are on long-term disability, your insurance company may cancel your claim. g)** Disability insurance claims that are being pursued through the court system can take anywhere from 2 -5 years to be resolved, so don't expect money to come quickly from your lawsuit. h)** Fees. Your disability insurance company may be responsible for paying your lawyer's fees. (#92056 Video3 @ 0:03). (1)** Some doctors will postpone their fees till after your case is settled. {PO}{Like everything, it doesn't hurt to ask} i)** Any legal settlement you make will probably have the amount of your future C.P.P. disability benefits taken off. Watch the time limit for applying for C.P.P. disability benefits, and if you are able, it might be an idea to apply for C.P.P. after you settle your case, so that your C.P.P. benefits will not be included in your settlement, thus increasing the amount that you receive. j)** Name drop. Even if you don't have written reports from particular specialists, G.P.s, psychologists, or allergists that you have seen, if they were good use their names in your general history letter. It adds more credibility to your case. k)** Tests that may help your insurance claim: (1)See if you can get into the sleep clinic at UBC. You will be asked to sleep overnight at this clinic. Your brain waves will be monitored while you sleep. They are looking for abnormal brain-wave sleeping patterns - it has been discovered that many M.E. and F.M. patients have abnormal patterns. l)** Medical report authorization form. Most insurance companies require that you sign a release form so they can have access to the medical report given by their "independent specialist". One support group leader has written the following on the form, and it works well for her: 'this signature is only valid on the condition that I receive full and complete copies of all medical reports, written or verbal, and that they are sent to my home address at the same time they are forwarded by this doctor". This statement ensures that you get access to these reports, which you are normally not allowed to have, and that the insurance company cannot get the reports without your signature. This works the same as if you are buying a house, where you have a "subject to" condition on an offer. The contract is not valid until those conditions are met; if the conditions are not met your signature is not valid, which means they are breaking the contract by getting that report. If you do not put this clause into the contract, then the contract is between your company and the insurance company, not you - you are not entitled to a copy of the policy in that case. #93931-2. (1)** Blanket Release Form. Some insurance companies will have you sign a blanket release form at the beginning of your claim, which allows them access to each doctor you have ever, or will ever see, as well as all your medical records. Be cautious on what you sign, and use the clause above to protect yourself. Never sign a blanket form. (2)** There may be an expiry date to this form - sometimes these forms are valid for only one year, but are still used by insurance companies after that. (3)** You can ask your G.P. not to send any reports without your permission. (4)** You might request your G.P. to ask your "insurance" doctor for a copy of the report - he may be kind enough to send one. m)** Frequency of reports. The insurance company has the legal right to have you or your doctor fill out forms whenever, and as often as it deems necessary. n)** Procedures for Insurance companies: (1) You have the right, when an insurance company sends you to their "independent doctor", to insist on a doctor of your gender. Legally you must see an independent doctor for assessment with regard to your claim. The word "independent" may be taken to mean "not on their payroll". (2)To my knowledge, other than a gender issue, you are required to see the doctor they refer you to, but you can request or challenge a doctor that they choose. Opening statement for this might be "Why should I go to a psychiatrist, when they are not the doctors that diagnose M.E. or F.M.? I will go to an internalist, a rheumatologist, or an infectious disease specialist that: (a)is educated enough to know that M.E. or F.M. are organic illnesses; (b)has diagnosed several people with M.E. or F.M.; (c)I will pay half of the fee so that we can both be assured that this is a truly independent assessment. (d)you can make this request, but it appears to be up to the insurance company's discretion whether they will act upon it. (3)** Insurance companies have an appeal process. This process is questionable, but worth a try. If you have insurance company questions, contact the Insurance Institution Commission With The Superintendent of Insurance, phone #660-2947. (4)** Never assume people received your letter - it might be lost in the mail or the recipient might have misfiled it. Phone to confirm that your letter was received, getting the person's name, date, time, and the particulars, or send it registered or double-registered mail. o)** Be specific on applications. Be cautious how you fill out applications and questionnaires for your disability coverage - be very specific about your limitations. eg do not say only that you cannot walk, express it more as "I cannot walk more than 1 block at a time, and suffer for many hours (or days as the case may be) after over-exerting myself". Many people have made statements to the effect that they cannot walk, then are caught by a private investigator who has video-taped them walking. The insurance company will deny you further benefits based on this evidence, as you "misrepresented" yourself and are able to do more than you stated you could. I am aware of at least 7 people from the B.C.T.F. (British Columbia Teacher's Federation) who have been followed and video-taped by a detective and subsequently been denied further benefits, because they were seen doing more than they had stated that they could on their application (eg walking to buy groceries). (1)** Pratima (Phone #421-0147 Burnaby) has agreed to collect names and be a liaison for anyone having problems with long-term disability insurance with the B.C.T.F. She is also investigating the possibility of a class-action lawsuit against the B.C.T.F. (2)** B.C.T.F. appears to have a tribunal type appeals process. #94017-3. (3)** B.C.G.E.U. (British Columbia Government Employees Union). For those who belong to the B.C.G.E.U. and are having difficulties with their disability insurance, contact Bruce Thomson, RR#2, Site 21, C30 Gabriola Island,BC V0R 1X0. (4) ** Unions and Contracts. During the time I have spent as a support group leader, "in general", unions are not very aggressive in helping people with M.E. or F.M. Press your shop steward and the union to protect you. Use their help - that's what you pay your dues for. Read the union and non-union contracts that you sign, to make sure you know your rights, and discuss this with your lawyer. A minimal fee (possibly over the phone) is worth the effort to make sure you protect yourself during the many years it takes to get over this illness. Don't assume people will be fair, just, and compassionate. p)** Appeal the decision if you are denied further benefits through your long-term disability plan. Most policies have an appeal process. q)** Rehabilitation Inspection. You may be asked, or required, to go to a rehabilitation centre for a physical assessment to determine your limitations. Bring someone with you, and bring a tape recorder so that you won't get intimidated as easily. Also bring your "specific history letter", as well as the one-page "general letter", and make sure it is read. Bring a letter stating that, as with all M.E. and F.M. patients, the problem is not only what you have difficulty with now, but to an even larger extent that doing this action may cause an increase in your symptoms over hours, days, or even weeks that it takes to recover from this physical test. From what I understand, you are required to go to this inspection, but you may give them this information. You have the right to stop when you have reached your limit and not over-exert yourself (eg ride their exercise bike for one minute and stop with a statement "This is as far as I can go without harming myself"). (1)** Leslie Tough, a lawyer from Winnipeg, Manitoba specializing in M.E., states that insurance companies can not force you to do tests contrary to what your doctor recommends. However the insurance company can "cut you off" as being uncooperative. {PO}{This appears to be the way a lot of the laws for disabled people work. It may be against the law to do something, but you have to hire a lawyer and take them to court to get justice.} r)** Resigning from your job. Don't resign from your job if you are ill. Legally, if you have resigned, and then try to go back after you have discovered the reason for your illness, or have more proof that you have M.E. or F.M., you will have a difficult time with the company, as according to their records you had left of your own free will. s)** Standard Insurance Company. If you are having a problem with this insurance company, you can call #1-800-366-6056. #94020-3. The CFIDS Association (as of 1993/07) was investigating unfair insurance practices such as phoning and harassing patients, and asking information. #93046-12. 11)** C.P.P. Disability Benefits #90049; #93058; #94022-8; #950103-9 a)** There are several examples of form letters for C.P.P. and insurance applications in the "M.E. and F.M. Library Materials" #90049; #93003 More information can be obtained by calling C.P.P. #666-3040 or 1-800-667-1277. b)Contact B.C. Coalition for People with Disabilities for assistance in filling out your C.P.P. application.!!! c)Get a computer printout from your pharmacist of all prescription drugs received in the last 2 years. This printout lists the prescribing doctor's name, the drug prescribed, and the price of the drug. d)** Include a list of all the favourable doctors you have seen on your application. You can call Medical Services Plan find this information. e)** Within the application package for C.P.P. disability benefits is a medical section that must be filled in by your doctor. Coach your doctor on what he needs to write - the following must be stated in order for your application to be approved: (1)You cannot be gainfully employed at the present time; (2)Your disability/illness is severe; (3)Your disability/illness is pro-longed (longer than 1 year's duration); (4)Your disability is permanent for the foreseeable future (using this statement allows the doctor some flexibility in his prognosis, as he may not want to state that the disability is permanent for all time). (a)** Another term your doctor might be more comfortable in using might be "possibly permanent", or "apparently permanent". (5)** Tell the doctor you will mail the form for him, and look at what was written. Your doctor must be accurate and precise in what he states. Many applications have been turned down due to vague or ambiguous answers by both doctors and patients. If you do not have a diagnosis yet, you are still eligible for the benefits, as long as you fit into the criteria. Read all of the material in the C.P.P. package provided by M.E.B.C. included in the "M.E. and F.M. Library Materials" (#90049; #93003) to be sure you are producing letters and information that will get your application approved the first time around. f)** C.P.P. has "independent Specialists" As of 95/10, C.P.P. is sometimes making people see an "Independent Specialist". I was told that they decide which specialist you will see from their approval list. You may be able to ask for that list and find a doctor who is knowledgeable on M.E. or F.M. You might try getting your specialist or another favourable doctor added to that list, then go to him. Please pass any names on to myself so that I can add the name to the doctor's list, and others can benefit. (1)** Neuropsychological tests. You may be requested to have this test done, after your C.P.P. application is reviewed. #950301-14. Many psychologists that are familiar with M.E. have shown these tests display that the major symptom of an M.E. patient is not depression. It is essential that you get a psychologist that is familiar and that believes in M.E. or F.M., that has done the tests before for an M.E. or F.M. person, and that he is up-to-date on the current information. g)** Optimism. #90041 "No note of unwarranted optimism should be included, rather the bleak factual prognosis should be spelled out even though we all wish to return to the workforce at the earliest possible opportunity." h)** When you are filling out your application, avoid statements that suggest that you are able to do light work at the present time. i)** Have someone who is familiar with your symptoms describe in a letter how your disability has changed your lifestyle. j)** Use the "specific history letter" as described previously in Chapter #11 to inform C.P.P. of all the pertinent facts, and how having M.E. or F.M. has effected your lifestyle. (1)** Details in your letter, not on the application. Do not put detailed information in the application form. Put down "Please refer to attached letter for details". This ensures that they read your attached letter, and it allows you to give more details. k)** Include your name and S.I.N. on all pages attached to the application. Your C.P.P. application goes to many departments before final approval. Identifying the pages minimizes the risk of pages being lost in the shuffle. l)Tell the truth in your application, but present the truth to your advantage. m)** There is about a four-month delay in processing your application. Approximately 70% of M.E. and F.M. applications are rejected on the first submission, but after the second or third appeal most people do finally get assistance. n)There seems to be a long delay from the time your application is approved to the time you are notified. You can call C.P.P. directly to find the status of your application. They will also tell you when you can expect to receive your first cheque. o)** Try calling your local M.P. to help with the approval of your C.P.P. application or appeal. p)** You have 90 days to make an appeal if you are turned down. You can have an extension of up to 6 months to make this appeal, if you request so by letter. Contact the B.C. Coalition of People with Disabilities for advice. According to the coalition, with their help your success rate on an appeal increases to 90% (95/08). Phone #875-0188/ fax #875- 9227/ #1-800-663- 1278. (1)** You must have a reason for making an appeal - you cannot say "It wasn't fair that you turned me down". q) ** Personal Disability File. You may request the entire contents of your file from C.P.P., so that you can look at reports sent in by a doctor who you might not be aware of, or to verify anything that might be detrimental to your case. r)** The National M.E./F.M. Action Network (3836 Carling Avenue, Hwy 17B, Nepean, Ontario K2H 7V2 Phone #(613) 829-6667) has a system in place to help with insurance matters. s)** Your application for C.P.P. benefits can be back-dated up to 15 months before the actual date of your application. You may be eligible for benefits even though you were late in applying. t)** C.P.P. benefits can be deposited directly into your bank account. u)** Most private insurance companies will insist that you apply for C.P.P. once you have been receiving long-term disability benefits for one year. If you are currently receiving tax-free disability benefits from a private insurance company, you may not want to put much effort into applying for C.P.P. Any benefits you receive from C.P.P. dated for the time you collected long-term disability (except those funds designated for your children) will have to be paid back to the private insurance company. You must also pay taxes on C.P.P. benefits. You will actually be worse off collecting C.P.P. benefits while on long-term disability. (1)** The Other Side of The Coin. Be cautious about not applying for C.P.P. benefits. If your insurance company stops paying you benefits, having the C.P.P. income would soften the blow. v)** You should apply for C.P.P. benefits as soon as possible after you become disabled, preferably within one year of your last employment. w)** C.P.P. may go back over the last 40 years of your employment to determine how much you will receive. Keep asking until you get the answer that you want. (1)** You can collect benefits even though you may not have worked in the last 10 years. As an example, if you had to quit work in order to raise your children, and are now disabled, you may be able to collect. (2)** If you are divorced, and have never worked outside of the home, you can "split the assets" of your divorced partner. I understand it does not affect the other person's benefits. (3)** You can collect the disability pension at any age, although you must have contributed to the plan in order to collect any benefits. In the case of a divorce, or spouse's death, that person must have contributed to the plan in order for you to collect any benefits. (4)** You can get benefits for each of your children, up to $157 per month per child up to age 18, and full-time students to age 25. x)** C.P.P. does not deduct any income tax at source - this becomes important when you receive your first benefit payment, since that one will include a lump-sum for any eligible back-payments (sometimes amounting to more than $10,000). Budget for this once you start receiving benefits. Taxes are not paid on your child(ren)'s portion of your disability benefit. The T4 you receive from C.P.P. includes only the portion that pertains to you, and does not include the monies paid on behalf of your children. (1)** C.P.P. will deduct your income tax on a monthly basis if you request them to do so. y)** When you complete your income tax return, decide which year the lump-sum payment should be used for - the year(s) it was back-dated for or the year it was actually received. According to the income tax department, claim the lump-sum payment for the year it was back-dated to, fill out your current year's taxes as though you did not receive the lump-sum payment, and the tax department will decide what portion of your lump-sum payment to apply to what year - eg 80% for 1994, 20% for 1995. They make the decision to whatever works best for your circumstances. z)** Your best effort makes your biggest success. Spend a lot of time with your application - your success rate is much greater the more extensive your application is. "It is much harder to clear the water after it has been muddied with poor doctor reports, or a bad application." aa)** Resume. If you previously had a resume, send this with your application to show what qualifications you have, as well as to give a more personal touch to your application. bb)** Stating your income while on C.P.P. When you apply for other benefits, state only your income, not the disability portion you receive for your children; otherwise your income might be above the eligibility requirements for some of the benefits. Unless specifically asked, you are not obliged to give out unrequested information. cc)** You can go back to work on a trial basis for up to 4 months without losing your benefits (95/06). However, you MUST make prior arrangements with C.P.P. I STRONGLY URGE YOU TO SPEAK WITH SOMEONE FROM THE B.C. COALITION OF PEOPLE WITH DISABILITIES FIRST!! C.P.P. benefits are easily terminated, but extremely difficult to have re-instated. If you go back to work, you may have to work for 3 years before you are eligible to reapply for benefits. #950603-1 (1)** Must take any job. Insurance policies generally state that after a period of time (1 or 2 years) if you can't go back to your original job, you must try to work at something else (usually 60% - 80% of your original salary), and within your educational background. If you are a teacher, you are not expected to park cars for a living. dd) You may be able to take 1 night school class without losing your benefits. However, again, please speak to someone from the B.C. Coalition for People with Disabilities for advice. ee)** Volunteer activities. As of April 7, 1995, you are able to do volunteer activities #950603-1 ff)** Re-assessment. You can be reassessed up to 3 times per year while you are on C.P.P. disability, depending on the illness. Of the people I have spoken to over the years regarding C.P.P. disability benefits, approximately 3% have been re-assessed, but not necessarily disqualified. gg)** Your G.P. or specialist may be contacted for discussions without your permission by the insurance companies or the government (eg Driver's License Renewal). Make sure you inform your GP of a possible call and your positive details, or that you insist that no information be given without your permission.-------------------