Does endometriosis qualify as a disability in Canada?
Endometriosis impairs the body’s functions and limits the individual from completing some basic activities. This means it falls under the umbrella of disability in Canada. Endometriosis pain tends to be constant, with a flare-up once each month. This guarantees that for at least a few days each month, the individual will be suffering, in some cases even bedridden.
Since endometriosis is an invisible illness, it can sometimes be challenging to prove and qualify for long-term disability benefits. Without visible proof, insurance companies often seek to downplay the severity of the symptoms and argue that the employee is still able to work full-time. Too often, people are bullied into suffering in silence because of the stigma surrounding endometriosis.
Employment and disability rights for endometriosis
Canadian citizens have rights that protect them in the Charter of Rights and Freedoms and the Canadian Human Rights Act. This means that those suffering from a disabling condition, like endometriosis, are entitled to rights and protections regarding their condition.
Along with the disability rights you are guaranteed in Canada, you also have rights as an employee. The human rights laws in Canada dictate that employers must assist their employees with medical requests to help accommodate their condition at work. Employees are protected from being fired over discriminatory medical reasons regarding their endometriosis.
Sick leave is a reasonable request that employers must accommodate as long as there is a valid doctor’s note. This letter should indicate the need for time off and the length of time required. Depending on how long the leave of absence is, a doctor’s note may be required every three to six months to prove you’re still unable to return to work. If you apply for long term disability benefits and are denied, you can remain on sick leave during the appeal process. The only requirement for this is the continued and updated submissions of doctor’s notes.
Know your rights. If an employer tries to fire you due to your endometriosis, you may be entitled to severance pay or the reversal of your termination. Hiring a lawyer to provide legal advice and help you navigate the situation can provide comfort and relief during this stressful time.
Types of disability rights for endometriosis
Not all disability insurance plans are the same. Here are the typical benefits included in Canadian disability insurance plans:
Paid Sick Leave
Some workers will have a bank of sick time to use in the first days of disability. The intent of this benefit is to allow the worker to have a few days to get back to work. Some workers may have many weeks or even months of accrued time to use.
If you do not believe that you will be able to return to work before your paid sick leave is exhausted, be sure to complete an application for disability insurance benefits right away. You do not need to wait until you have used all your paid sick leave before submitting your application. Also, it is always easier to work on a disability application while you are being paid so don’t wait until your benefits have run out.
Another major reason not to wait to apply for STD Benefits is because of deadlines that may apply. You may miss the deadline to apply for benefits because you are being paid sick leave benefits.
Employment Insurance Sickness Benefits
Your alternative to paid sick leave is government provided employment insurance (EI) benefits. Most workers have fewer than 15 weeks of paid sick leave so EI benefits will make up the difference between the expiry of paid sick leave and a STD Benefit. EI Benefits must be applied for through the government. In order to apply, you must obtain a medical report from your doctor and a Record of Employment (ROE) from your employer.
Go to www.servicecanada.gc.ca for information on the EI sickness benefit and to download the application forms. Service Canada will not process your application until both the medical form and the ROE has been submitted, so be sure to book a doctor’s appointment and request your ROE right away.
Short-Term Disability Benefits
The first of two main benefits in most disability benefit plans are STD Benefits. The purpose of STD Benefits is to provide you with income while you are unable to work due to illness or disability. The Benefit is designed to cover short absences and not intended to be a long-term solution.
STD Benefits provide a weekly or bi-weekly payment for a number of months. The short pay periods are designed to provide you with uninterrupted income while you are absent from the workplace. Most often, you will be required to use accrued paid sick time before accessing your STD Benefits. While cashing in sick time may be frustrating for some, it is wise to accept this condition because the sick time should provide you with more income than the STD Benefit.
The STD payment typically provides for a percentage of your regular weekly earnings or a specific amount of money. The benefit payment calculation details are specific to the policy and set out in the insurance policy document.
Payment examples include:
• The worker will be paid 60% of his or her pre- disability weekly earnings, or
• The worker will be paid $500 per week, or
• The worker will be paid their pre-disability weekly earning, up to a maximum of $500 per week.
Most STD Benefits last between three and six months. If the group plan does not have a LTD Benefit, the worker will have no further benefits under the group policy.
Long-Term Disability Benefits
LTD Benefits are the second major element of most group disability plans. There are some plans, however, that only include LTD Benefits. If your plan has both STD and LTD Benefits, a disabled worker will ‘roll over’ to the LTD Benefit at the expiry of the STD period if they are eligible to do so.
Eligibility for LTD Benefits is not always a given. Workers often earn their eligibility to the Benefits through working continuously for the employer for a number of months.
Eligible workers will be able to make a claim for LTD Benefits if they have been out of work continuously for a specific period of time. This period of time is typically the length of the STD Benefit. This period of time set out in the policy wording is referred to as a “waiting period” or “elimination period”. LTD Benefits will not be paid prior to the elimination period; however, benefits will be paid for the total period of continuous disability if the claim is approved.
Benefit payments under a LTD Benefit are assessed based on a percentage of your pre-disability income. Typically, the benefit will be between 55% and 75% of your regular earnings, or a set amount of money per month. Other polices will have a net formula.
Payment examples include:
• The worker will be paid 66.7% of their monthly pre-disability earnings, or
• The worker will be paid $3,000 per month, or
• The worker will be paid 66.7% of his or her monthly pre-disability earning up to a maximum of $3,000 per month.
The exact payment formula will be set out in the policy document. Be sure to refer to your policy to confirm what the applicable payment formula is for your claim.
The LTD Benefit will make payments on a monthly basis for a set number of years (e.g. 5, 10, 20), or until you reach a certain age (e.g. 60, 65, 67). Some plans may have a benefit termination formula where a mixture of the years a claimant received benefits and the claimant’s age is used to calculate an end date. Generally speaking, the latest date where a claimant will be eligible for Benefit payments is called the Maximum Benefit date.
How to win disability benefits for endometriosis
The first step in filing your claim for long term disability benefits is getting a proper medical diagnosis. Without a complete medical file, insurance companies will deny the claim. An official diagnosis method includes a pelvic examination, ultrasound, an MRI, or laparoscopy. It can feel invasive to share the results of such personal medical testing with your employer, but it is necessary to receive long term benefits.
After diagnosis, insurance companies want to see that you’re working on managing your endometriosis symptoms. Seeking active treatment is key to being approved for your benefits. This includes taking medications to manage the symptoms, and often surgery is required for those with endometriosis. Working closely with your doctor to present an entire, complete file of medical evidence is a necessary step in winning your long term disability benefits for endometriosis.
After receiving your official diagnosis, you’ve completed the first task. You must now demonstrate to your insurance provider that you have made every effort to continue working. This includes requesting fewer hours, lighter duties, or a different role to accommodate your endometriosis. Your employer must work with you on this. Demonstrating that you have attempted to modify your duties and remain employed is vital in having your claim for long term disability benefits approved.
How to hurt your long term disability claim for endometriosis
- Presenting an incomplete or inconsistent medical file regarding your endometriosis
- Missing documentation proving your efforts to maintain regular employment
- Having a poor attitude towards those working on your claim
- Unnecessary stalling or blocking of reasonable requests from your insurance provider
How to improve your long term disability claim for endometriosis
- Having an official medical diagnosis of endometriosis
- Presenting a full record of medical evidence detailing any tests, medications, or surgeries regarding your endometriosis
- Showing a detailed record of time missed at work, modifications made to your role, and any other efforts to accommodate your condition at work
- Being cooperative to those involved with your case
Common reasons for denial of endometriosis claims
Most long term disability claims are denied due to a lack of evidence. Insurance companies want to see that the benefits are being claimed as a final step after exploring every other avenue. If there are gaps or holes in your claim, it will likely be denied.
For instance, if your family doctor has diagnosed you with endometriosis but hasn’t put you through the relevant testing for an official diagnosis, you are likely to be denied. This is why being involved in your medical record is essential. Ask questions, and make suggestions, to advocate for yourself and your health. An official diagnosis is only completed in the eyes of an insurance company after all the testing has been done.
Long term disability claims are also denied when the insurance provider doesn’t feel there has been an adequate effort from the employee to stay employed. These companies want to see you trying to find a way to keep working, so going on sick leave without talking to your employer will raise a red flag. Be involved with your employer and work together to make solutions for your condition. If this doesn’t produce results, you can begin compiling your long term disability benefits claim.
For those with endometriosis, this process can be grueling. Being prepared with the knowledge of what you must undertake to have your claim approved successfully is vital. Having a lawyer to help you through this process and avoid any surprises will streamline this process, leaving you with the financial security to focus on your health.
What if your claim is denied?
Know that you are part of a large group of Canadians who have had their benefits denied by the insurer at some point during the course of a claim. Those who have been issued a denial letter are those who had their application rejected by the insurer. They were deemed eligible to apply for benefits, but not totally disabled and therefore were not approved for benefits. Those who have been issued a termination letter are those who were approved for benefits but were then found not totally disabled. The insurance company generally chooses to terminate benefits at or before the two-year mark from the date of disability.
For those who have been denied, some will be legit mate because the applicant is not in fact disabled. Other applicants are truly disabled but were simply denied by the adjuster because their application was not strong enough to warrant approval. Of course, the insurer would prefer that denied applicants forgo the appeal process and not sue for benefits.
For those who were approved and then cut off sometime afterwards, the insurer is attempting to ensure that the denial is accepted by the insured during the “own occupation” period. This is ideal for the insurer as it may prevent appeals or legal claims. Thus, it allows the adjuster to close the file well before the Change of Definition date occurs.
You cannot change the fact that the insurance company denied your claim. However, you do have complete control over what you do in response to the denial or termination of benefits.
The options available to the applicant will depend on what is permitted by their policy or plan. In most cases, the applicant can advance their claim to an internal appeal mechanism or commence a lawsuit. If a plan is through a non-profit disability benefit trust fund, it is likely that only an internal appeal mechanism will be available to them. For these workers, they have been denied the right to have a neutral court decide whether or not they are entitled to benefits.
WHAT IS THE DIFFERENCE BETWEEN A DENIAL LETTER AND A TERMINATION LETTER?
It is a bad day for any disabled worker when they receive a denial letter or termination letter. The letter is essentially a rejection of financial support in a time of need and it leaves most people very worried about their financial future. After receiving a letter, some disabled people experience severe declines in their mental or physical health because it feels like their expected safety net has been ripped out from beneath their feet.
What the disabled person does after receiving a denial letter or termination letter is critical. First, be sure that you keep a copy of the letter. Photocopy and safely store a copy of the letter before making any marks on the letter. Any competent disability lawyer will want to see a clean copy of the letter to review at an initial meeting.
The denial letter is also important as it offers a window into the insurance company’s decision-making process on your file. The letter should (but does not always) spell out what information was reviewed and what findings were made with respect to the information in your file. The insurer should explain why your application was denied, or why you are no longer entitled to benefits. For new claims, the denial will typically mention that while your injuries cause you to suffer some restriction, you do not meet the test for total disability. For cases where a benefit termination letter is sent, the insurer will often mention that activities (often from surveillance evidence or information from phone calls) are inconsistent with reported restrictions and limitations. The explanation provided in other circumstances will parrot select wording from the medical expert chosen by the disability insurer. Once you have sorted out why you were denied, you can then determine what you can do to attempt to overturn the unfavourable decision.
Warning! There is a lot of misinformation about insurance policies and the rights that come with them. Do not rely on the word of a union representative, co-worker, or supervisor to explain your rights and ideal strategy when facing an insurance benefits claim. This is especially so where there is no right to sue. While they may have the best intentions, they may not have the best advice. Contact an experienced disability lawyer to avoid a major claims mistake.
