Change of definition date and end of coverage

Disability Insurance
1

Hi, this is my first time posting here, and I know there’s been a few questions asked about this kind of thing, but then again every case is a little different right?

I’ve been on disability insurance since December of 2019, as a result of deterioraring mental health, exacerbated by a stressful, toxic work environment. This is actually my second DI claim with this provider. The last time was only for a year and a bit, and ended in 2012. The reasons were similar but this second time was much, much worse.

This week I Was informed of two things by the case manager: 1: I would be contacted by an occupational rehab specialist in a few weeks, and 2: benefits will not be paid beyond the 2 year “change of definition” date unless it were determined that I were still unable to work.

I know I’m probably wording it wrong, but basically they said no more payments beyond that date unless new information is presented that basically provides evidence for my incapacity.

This was surprising to me because:

This is my second claim, which provides support to the fact that I Have a chronic illness;
I have tried many treatments during and before my claim, including TMS, Intensive Outpatient Therapy, a bunch of different antidepressants (including two that are so old and “risky” that only psychiatrists will prescribe them), antipsychotics, mood stabilizers, sleep aids, client-centred counselling, CBT, and others I can’t recall at the moment.

Right now I’m considered “treatment resistant”. I should also mention I regularly see a psychiatrist and a Therapist. I’m currently waiting to hear back on insurance coverage for ketamine therapy, which will hopefully start soon. I also got a referral to a consulting psychiatrist, who is going to do a neurodevelopmental assessment on me, to see if I have undiagnosed ADHD or autism.

It’s really frustrating because I’m still not better, but I’m doing everything I’m supposed to be doing in terms of treatments. You’d think that would be enough for the coverage to continue, but no. Maybe they’re waiting for the rehab person to say I’m not ready? Maybe they want me to try (and possibly fail, with my luck) the ketamine?

The claims person assured me it’s not a final decision, but my instinct is not to trust them.

So, should I start the appeal process? Call a lawyer? Wait to talk to the rehab consultant?

Thanks for reading

2

I sympathize.
My only comment is I think it is especially hard to prove a disability claim for mental illness because it is hard to prove to them that it is permanent.
Best wishes.
Hopefully someone with a mental illness claim will chime in.
I wouldn’t appeal anything until there is something to appeal. :slight_smile:
BUT I would get the free consult and see what a lawyer says:
Free Consultation Request — Resolute Legal

3

Have you applied for CPPD, insurance company can cut you off anytime whereas CPPD does give you more secure payment per month if approved.

4

Hi,
LTD tries to terminate everyone at 2 the yr mark.
Becareful with the rehab they send you to. They often work more for the insurance company and not for you. If it’s too much and you notice things are not right go to your doctor and tell him or her everything. Thrust me…they will put you through hell if you allow it. I would appeal the decision and write exactly what you wrote here…then follow it up with asking them if they have any medical reports that state you can work? If your doctor are on board with you then there’s no way the insurance company has anything that says you can return to work. That’s how I appealed mine. For me…even the doctor they sent me to for an assessment said I couldn’t work until my issue was resolved. They tried to cut me off too. My appeal was short and sweet. I said if you can provide some medical documentation that says I can work then I guess I have no choice to return to work but to my knowledge everything you have states I cannot work.
I was approved no questions. Ask them to provide you something that says you can work.
Good luck. Always keep your guard up with rehab. Don’t let them bully you.

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5

No, I haven’t applied. I’m hoping I’m going to improve with additional treatment and rehab, so is it worth even applying? Is it a long process? What if I get approved for CPPD and then feel better?

Man, this is the tricky part. Mental disorders get better and worse depending on the day or week. They’re not constantly 100% disabling 24/7, which makes claims harder than for physical injuries. Maybe I should apply, I don’t know.

6

Thanks! I’m going to do that

7

Hi, some physical conditions are variable like that too, like multiple sclerosis or autoimmune diseases that flare up from time to time.

So, I think you may be misunderstanding the phrasing a little bit. No matter how long you are disabled, it will always be a condition of payment of your LTD insurance that you continue to be unable to work. So don’t read too much into that phrasing itself.

Every policy is a little bit different but how it generally works is that for the first two years you just have to be able to do your own job. After the two years mark, you have to be unable to do any job of a type/nature/payscale that would be suitable for your education, skills and experience. If you are still too sick to work, you are still too sick to work. Maybe the occupational therapist will be able to figure out a way that you can work, that would be the best outcome, but if they can’t, then you will have shown good faith efforts to try to get back to work which strengthens your position and credibility.

One thing that popped out, you mentioned that your condition was not caused by the toxic employment environment (which is good because insurance doesn’t cover crappy workplaces, the expectation would be that you find a less toxic employer) but was made worse by it. If you would be able to work in a less toxic workplace then that might be the next step; if you can’t, then it would be more evidence of disability. Most LTD allows for attempts to return to work with the ability to restart your LTD insurance if the attempt fails.

8

Ok thanks for clearing that up a bit. The comparison to autoimmune diseases is pretty spot on. There are some days where I feel like I could put in a day’s work and be ok, but then the next day or a couple days later, I can barely take care of myself and do simple chores.

And yes I was reading the policy document and it says I’d have to be unable to perform the duties of any job that I am reasonably qualified for, based on my education, experience, and ability. It would also have to pay at least 2/3 of my pre disability pay. Now, I wasn’t in a high paying job, but this also eliminates minimum wage jobs from the realm of possibility. Not to disparage those who work those jobs, but it would be adding insult to injury.

Last time I made a claim, I went through the return to work process, and it was a very frustrating experience. Maybe my expectations were unrealistic, but for about 2 years I got shoved into random administrative assistant jobs that I had no experience in and had no interest in. I came up with some ideas and even took courses at my own expense, but for whatever reason, the process is so slow and bureaucratic that I was completely shut down at every turn. I eventually got placed in a dead-end position that did no favours for my mental health. I was already fragile to begin with, but I managed to stick it out for several years before I completely shut down.

That’s probably my biggest fear: I’ll be forced into a return to work position, deteriorate, and go through the process all over again. You’re right about the part where if I don’t do well, I go back on LTD. I’ll just have to look up what the time limits are.

I’ll make a good faith effort with the rehab program and see what happens. Maybe it’ll help, and they’ll recommend things like flexible hours, telework, training, or who knows what. I seem to recall meeting with a rehab consultant last time, but I don’t remember much coming of it. I think basically the recommendation was to take a different job that was less stressful. I really hope that’s not what happens this time. Sure, my job had serious issues, but that’s not the reason for how I’m doing.

But thanks again everyone for your kind words and advice

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9

I could have written your exact post. I went through the same. 2 disability periods with same insurer. First time off 5 months, 2nd now 5 years since I’ve been back to work. I went through the same COD threat and it really messed with me. Out of the blue, an OCC therapist called and said they were going to start transition back to work. I had an instant panic attack and was sobbing on the phone to her.

She said it was very clear I was not ready and would report back to the insurance company as such. After that, they tried the IME psychiatrist. It did not pay off for them. He dx’d me with complex ptsd and advised them that I wouldn’t be able to return to work. My psychiatrist sent in the paperwork to apply for CPP-D which was approved first try in 4 months.

Once that happened, the COD was approved to ANY occupation. That was a couple years ago.

I know you didn’t need all that history but I wanted to show how it is possible to get there. A great advocate in my psychiatrist was the key.

I wish you luck. They will try anything to be able to stop paying you. It is so hard when you are dealing with poor mental health.

10

I’m so, so, so glad to hear that I’m not the only one who went through this. I know that a rehab consultant/ occupational therapist will contact me soon, but if they just say they’re transitioning me back to work, I’m going to lose my mind. I want to get better in all areas, not just kinda sorta well enough to go back to work. That’s what happened last time.

My psychiatrist probably wrote that I might be able to do some kind of work in the future if I improve, although I can’t go back to what I was doing before. I guess to them that means I should be able to work, and therefore off their caseload. It’s bullshit of course as we know, because the insurance is always looking for a way to weasel out of paying.

Hopefully my neurodevelopmental assessment will shed some light on why I’ve struggled for so long. Maybe it’ll prove that this is more than just a simple one-off mental health episode.

Anyway, hopefully my meeting with rehab will show them… Something. I don’t know. I can’t just be put in some office somewhere full time and be expected to function. I’m hoping for some kind of skills training or something positive and productive that will make me feel better about myself.

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11

I wonder how it all turned out for you? I too had to leave work due to my mental health, I was diagnosed with cptsd and Bipolar 1…weirdly at my 2yr mark, they stopped paying me but didn’t say I was cut off…it was really stressful. I made it through, but they continue to push for a back to work plan despite telling my employer I would never return (they fired me after that for frustration of contract).

I finally got them to stop trying to call me, but now they’re wanting to talk on the phone again…I’m fighting that too for the second time.

Over the course of my claim, I’ve been bullied and abused by their agents…my complaints didn’t get me far, and I continue to feel super stressed worrying they’ll cut me off for some ridiculous manufactured reason…I’m so exhausted from the lies they tell me about my Doctor and honestly there are days I want to tell them where to go (I don’t of course!).

I’ve applied for cppd twice now and am praying that my claim will be accepted so I have something to fall back on…I would love to be well enough to go back to my profession, I loved my work…just not the toxic environment.

You’re not alone, there is hope, though at times it may feel grim, it will work out, just be very clear with your Doctors, it’s hard at times to communicate our needs when we are suffering mentally.

12

I’m in a similar situation, in that they aren’t closing my claim, but they’re not going to pay me beyond 2 years. I had a return to work meeting with manager and the union, and basically I have to get my doctor to outline what kind of restrictions I have and what I need. Then, they can go from there and try to see what some reasonable options would be.

I have no idea what they’ll offer though. I’m going to give it a shot and see how I can handle it. Maybe it’ll go ok. My fear is that they’ll either say they can’t work with my restrictions, or they’ll put me somewhere really terrible and I’ll be back to square one.

I have to think positive though

13

I consulted with a lawyer when that happened. He advised I write a detailed letter to them mentioning the legal consultation I had…asking them to reinstate my payments otherwise legal action would be made…they didn’t have a leg to stand on, so they had to pay me.

You seem to be handling this well! I guess all you can do is follow your heart here, only you can say what is going to work for your health…I wish you all the best!

14

Hi Bender, keep in mind if you try a return to work and it fails within 6 months, you can go back on your existing disability claim. It is common to get stuck in a no-mans land where the insurance claims you can work, but you aren’t able to work at a level to earn 60% or more of your pre-disability income. If that happens, you may have a strong case to keep LTD benefits after two years.

David Brannen

Disability Lawyer with Resolute Legal

The response posted above is based on the limited factual information made available and is not intended as a full and complete response to the question. The only reliable manner to obtain complete and adequate legal advice is to consult with a lawyer, fully explain your situation, and allow the lawyer enough time to research the applicable law and facts required to give an adequate opinion. The basic information provided above is intended as a public service only, a full one-on-one discussion with a lawyer should be done before taking any any action. The information posted on this forum is available to the viewing public and is not intended to create a lawyer client relationship with any person. If you want one-on-one advice, please click here to request a free consultation or call toll free 1-877-917-7050 to speak with a member with our disability claim support team.

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