Nearing the end of my claim


#1

My LTD claim reaches the 2 year mark in April. After a multitude of investigations,temporary dx a retiring GP, I was given a dx of Fibromyalgia in November. Following the dx, I was told I would be placed on the “rehab” program.I had a series of psycho-social questionnaires thrown at me in mid-Dec. Met with an OT the end of January for more psycho-social testing (this was after I had contacted my insurance co to ask what was going on). She suggested things like relaxation skills, a housekeeper, scheduling, etc, I did not agree with this person, which was not appreciated. I have worked for close to 30 years as an RN, most recently in the Mental Health field. I am well versed on the above suggestions. Then nothing again until March 3rd (again after I initiated contact);at which point I had a functional scan by a student,which lasted 40 minutes.I did poorly and had difficulties for several days after. My new GP believes I am either at the high end of the Fibromyalgia spectrum or that I am misdiagnosed. She has referred me for a 2nd opinion, Regardless, my functioning is poor. I have difficulties physically managing each day. There is very little doubt in my mind that a return to work would be successful.I have not been encouraged to apply for CPP, although my GP is willing to do so. When I had 1st questioned the LTD case manager, she told me not to. I have sent several letters of my concern with daily activity journals to this company and am receiving minimal response. Now, I am concerned that I will be suddenly left without income next month. Should I apply for CPP, do I appeal should they terminate? What a horrid place to be…thanks


#2

I am not a lawyer, but helping my spouse through his claim.
I would be concerned that your Insurer is not pushing you to apply for CPP-D.
Typically after a year the Insurer has to give you 30 days notice before ending your benefits.
I would ask for a complete copy of your claim file ( You should not have to pay for it).
If you apply for CPP they will often request your medical information from the Insurer-so you should have a copy too.
Often Insurers use rehab to get reports that are slanted/biased against you.
As a nurse do you have a union to help?


#3

I agree with Allyoops’ suggestions. It is unfortunately very common for insurance companies to wrongfully terminate people’s disability payments at the 2-year mark when the definition of disability changes from “own” occupation to “any” occupation.

Your are supposed to be given advance notice of any claim termination, but they may have covertly already done this in prior letters to you where they point out this change of definition date and say benefits will terminate if you do not meet the other definition of disability. They try to say this qualifies as giving you notice.

Once an Insurer decides to terminate your claim at the change of definition date, it is virtually impossible to get them to voluntarily reverse that decision using the internal appeals process, even if you have very strong information coming from your doctors. You are forced to file a lawsuit or start union-directed arbitration proceedings if your plan is 100% governed by your collective agreement.

Don’t lose hope, it is possible to get them to reverse course but it may have to happen in the context of a lawsuit or arbitration. I recommend you apply for CPP disability immediately if you are not able to do any type of employment, which sounds like is the case right now.


#4

Thanks for the input. The Nurse’s union does not get involved in Disability claims. Should my claim be closed soon, should I attempt a return to work? If I did so without success (which is what I anticipate), then have I damaged or delayed my LTD appeal or CPP Disability claim? I do know that when I initially filed for LTD, my claim was delayed an extra month as I had attempted to work one day. Am I better to just start with an appeal as I wait for a reply from CPP? At what point does one start the appeal process? Of course, finances are the main concern at this point. I am just unsure what to do at this point.


#5

Why did the Insurer cancel rehab? Do you have copies of the occupational therapist report and the functional report?
Again please request your claim file because it likely will surprise you and give you some insight on how the Insurer is thinking. The OT and the functional tests may have said you could manage sedentary work.
What is the definition of disability after the two year mark?
I suspect the Insurance company is going to say that although you can not do the duties of a RN you could work as a unit clerk or something along those lines.
I would send the Insurance company an update on your next specialist appointment and outline your current treatments. Perhaps a referral to a psychiatrist or psychologist would be helpful. Living in limbo with a chronic condition, pain and stress is hell. Not sure if you have tried physio, acupuncture or other treatments.
My heart goes out to you.
I would lean towards applying for CPP since you have a supportive Doctor and then let the insurer know you are doing so.
The other option, which has pitfalls, is to request more rehab through the insurer. That way if you try a return to work and it fails you are still on claim. The pitfull is that it is a fox guarding the henhouse when Insurers help with rehab.
Terminating benefits without legitimate medical evidence
to support such a decision may expose insurers to claims for mental distress or even
punitive damages.


#6

They did not cancel rehab. It has just been very passive. I do not have copies, but plan to request them. I doubt they have received the functional scan as of yet.OT asked if I wanted to see a psychologist. I declined. I have worked in Mental Health for the past 15 years. I know the field. OT then cancelled my sessions and was passively angry with me. I suggested the functional scan as my physical limitations are my problem. I could not manage an 8 hour work day as a clerk or otherwise, plus my current nursing job is an office job, Not much physical labor involved. The definition of disability is that I cannot perform at “any” job within a specific geographical area that would offer me at least 75% of my income. Why anyone would voluntarily pay into such a program is beyond me. It is not optional for nurses. Have tried it all and then some. No specialist appt date yet. It may not come before my deadline. Thanks for the input.


#7

You have a very favourable “own occupation” definition of disability. If you get denied, you should appeal because it is usually very hard for a professional to earn 75% of their former income working in “other” occupations.