Change of Definition Reversal

Over a year ago I was advised that my benefits would continue past the 2 yr mark. The case worker advised that my definition was changed as it was recognized that the surgery I require has been delayed due to COVID. I have still not had that surgery and my condition remains unchanged. In late fall a different case worker stated I must reapply for ODSP though I was declined the first time as presumably the required surgery would enable me to return to work. I did apply, and to date no response and neither has my case manager inquired as to status. Then in the new year I was advised that because the surgeon did not respond to 3 separate requests for a surgery date my benefits were being (and were) cut off. My GP wrote a letter and I believe my employer advocated on my behalf. Ultimately benefits were reinstated and retroactively paid. Now my case worker has sent me a return to work schedule advising that my condition does not have any restrictions or limitations to perform my job and provided a date after which my benefits would cease. 3 times I have requested the case worker to provide the “expert advise” from their medical consultant. Still nothing. 3 times I have inquired as to the apparent reversal of the decision to ignore the change of definition approval. No response. I have an appointment scheduled with my doctor to discuss. Has anyone else had a similar experience?

This what I would do…

  1. Get a letter from your GP stating what your functional limitations are, that you are physically unable able to return to your or any occupation at this time due to your condition, that you are making every effort possible to get the reasonable treatment required for your condition, that you are following all of your doctor’s recommendations, and that a mandate to return to work is completely unreasonable and against sound medical advice.

  2. Send the the doc’s letter with your own cover letter, and let the insurance company know that their return to work mandate is unreasonable and therefore in breach of your LTD contract. Let them know as they are being unresponsive, unreasonable, and have announced a date that they will unjustifiably cut off your benefits you are taking legal action to get this infront of a judge unless they reverse their decision by xxx date (I’d give them 3 weeks).

  3. Immediately (pick up the phone today) talk to a lawyer that specializes in LTD and works on a contingency basis (ie they will charge you nothing to review and execute your case until you get a settlement or benefits reinstated). A lawyer who wants a retainer for an LTD case will be pretty much useless at helping you.

Get this all done as soon as possible.

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The insurance companies say one thing and do another thing. It is really hard to trust what they say. My LTD insurer asked me to apply for CPPD and told me the test to get accepted to CPPD was much harder than LTD which is definitely the case. I often wonder when the insurer will change their tune and say well the test for LTD is different (harder) than CPPD and try to cut me off. I have a 3 year own occupation before it goes to any occupation and I am only at the 2 year mark now.

I wonder if what they say about CPP-D being harder is in fact correct. CPP-D is only approved if you are incapable of “gainful employment” which they see as $16K annually. If you are capable of earning more than $16K, then you should be ineligible for CPP-D. However, when you reach the “any occupation” definition of the LTD policy at 3 years in your case, how do they define/view “any occupation”. Your LTD policy’s view of “any occupation” may in fact be higher than $16K. Say the LTD policy’s view is that if you can earn $30K or more annually in “any occupation”, then you are ineligible for LTD benefits. Then what they said would in fact be correct. “Any occupation” does not literally mean any occupation at all … whereas it does mean this for CPP-D. Find out how LTD views/defines “any occupation”.

I checked my LTD approval letter. There is no mention of $ when any occupation but this is what is stated:

To qualify for benefits during this period, all information must support that you’re not able to work at any occupation because of your disability. ‘Any occupation’ means any type of work you could do based on your level of education, any training you’ve received, and your experience. We assess your condition and ability to work throughoutthistimetoconfirmifyoucontinuetoqualifyforbenefits. Theavailabilityof work is not considered when assessing your disability.


Also the common law (precidents judges use if your LTD denial ever goes to trial) supports that the any occupation clause applies if you aren’t able to earn 2/3s of your pre-disability income.

My income was $60,000. 2/3 of that would be $40,000. Since I have been approved for CPPD they claim I can’t do over $16,000 of work. I am sure the LTD provider will try hard to cut me off.


Yes, I’ve heard the same as Buckets365, 2/3 of former income has been used to assess “any occupation”. Given your numbers Harvey23, I think it may be hard for the LTD provider to cut you off at year 3 unless they make the argument that you have improved a lot between the time CPP-D assessed/approved you and your Yr 3 any occupation date. Hopefully that won’t happen. Also, this is the first time I’m hearing about a 3 year own occupation period, I though they are almost always 2 years. I’m curious which large employer you may work for.

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Yes I do work for a large government crown corporation, 1000 employees. Definitely benefits of a 3 year own occupation. My concern is still when we get near to any occupation. Along with CPPD approval I have been approved for the DIsability Tax Credit (DTC) which I informed the insurer about as well.

If your income earning ability stays far less than 2/3s your pre-disability income, you’re approved for CPPD, and approved for DTC you’d have a slam dunk case on your hands if your insurance company were to ever cut you off. I wouldn’t want to be that insurance company if you had a half decent LTD lawyer and are willing to take it all the way to court.

I am in an union environment so it goes through the union process, arbitration but I am hoping it never gets to that.

This sounds like typical insurance company behavior. I’d just tell them to talk directly to my Doctor as they have advised you not return to work and support your being off work. A written statement would be helpful too!

It’s deplorable the way they treat people who already have a ton of stress with their illness and loss of income nevermind the fear the insurance companies attempt to instill in us.

I’ve had countless scares, and everything always works out in my favor after my Doctor speaks directly to them.

Hope this helps!

Most union bargaining agreements allow for (or are silent) on if a law firm can take on an LTD denial or dispute for you instead of through the union. If you ever have a LTD hiccup have a law firm (specializing with LTD) to take a quick look at your bargaining agreement, and they can let you know in about 5 mimites if they are able to help you. Cheers.

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