Re: update by caseworker

Spoke to my caseworker today for an update. I am worried about whether they will continue with my LTD or close off with this insurance. Maybe this is just a vent but if you have to appeal the decision re: LTD, this appeal can take months with no income - I won my last appeal while on STD which took almost 3 months with no income - extremely stressful!! and am now on LTD but who knows upon heading to the two year mark. My symptoms have actually got worse. They are going to get up dates from my Docs and then make a decision 6 months prior to the 2 year mark. They say that they make a decision early. She said that I should try not to worry via conversation with me. I was also asked about when my next date is for my next acrual insurance review for my pension. It is a 2 year review and is not until next Sept… She ended up having that info in front of her - maybe she was testing my memory but not sure why I was asked about that. Any thoughts and is this normal procedure? I was also asked if fatigue is my major symptom and I said that all my symptoms are major and began to list them including SOB. I think I am just getting paranoid.

The more responsible insurance companies will give you a decision six months before the common 2 year change of disability defintion (COD) date. I call this responsible because at least they are giving you time to appeal while your benefits are still being paid. If you get a notice of denial in a situation like this, start your appeal immediately.

Keep in mind that once an insurance company decides to terminate benefits at the 2 year mark, it may be impossible for you to get them to “voluntarily” change their mind using their internal appeal process. This is because they usually have lots of information on you at this point, your doctors have given lots of information, they have hired their own experts to support their decision to deny the claim, etc.

You can still have a denial decision reversed at this point, but it may require you taking legal action. Filing a lawsuit can result in the insurance company voluntarily reversing its decision – this is in part because once you file a lawsuit, your claim is transferred over to new people within the insurance company. Your claim goes from the “appeals” department to the “litigation department”. The over-riding goal of the “litigation” department (in my experience) is to get rid of lawsuits, and in some cases that can mean a quick approval of the claim. I discuss this in more detail in my book: A Beginner’s Guide to Disability Insurance Claims in Canada.

We have this happen quite often – and even this week we had the litigation department contact me to apologize on behalf of insurance co because the appeals department had been unreasonable in denying claim at 2 year mark. They paid our client’s legal fee for hiring us and having to sue them.

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 reliabile 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 1-877-282-5188 to speak with a member with our disability claim support team.

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That is very good that they will give you 6 months notice. If you need to assure yourself then write and ask for a copy of your claim file for your records.

Personally I would want in writing that they promised you 6 months in advance on the change of definition date-but always ask in the most polite of ways. Having your claim file helps to see where you are at. It may give you peace of mind if it is documented fairly.

Great West Life only informed my husband two months prior to change of definition.
They started pushing for him to apply for CPP-D 8 months prior to the COD date and we did apply just 3 months prior for CPP-D.

I believe GWL was having him apply for CPP-D so they could use a denial from CPP-D as proof he could do some sort of work and access his CPP-D file as an investigation tool. But we would not sign the forms allowing them that info.

In the alternative, since he ended up being approved they would win by the over-payment/off set.

But since they breached the contract and estimated his CPP-D prior to approval we are arguing that they no longer can rely on the contract to claim the over payment…

Now we will let the court decide or see how they respond. We have had a hellish experience-but not everyone does.

He had two prior claims with GWL that went well. It all depends on who is managing the file I presume

That will be a very interesting outcome.
I hope you win that.

Thanks so much for your information. I also have another concern and maybe unfounded. When I initially applied to STD, they gathered info from just my two specialists and not my Family Doctor. (did not want to hear from my Psychiatrist & making it clear this was not a claim for my emotional/mental state - even tho they wanted info on my cognition) I have a systemic disease which includes more than just my heart and lungs although these are very important areas.
At that time, neither specialist was really in a place to comment about the impact of the systemic disease on my overall functioning or my emotional/cognitive state. As you probably know they have a very narrow focus on the organ they specialize in and they were being asked more general questions that are not in their area of practice. So some of their comments were extrapolated by the insurance co. to the whole body and functioning There was one line from a report by my Cardiologist that was taken out of context and they also asked him to comment on my cognition which was out of his realm of practice - memory/concentration. So after being on STD for a few weeks and getting close to moving onto LTD, I was initially declined because “they did not have enough info” even though they had access to my hospital file and did not talk to my Family Dr. I believe it was a summary letter of my condition by my Psychiatrist/therapist I see weekly (sent to them but not asked for - under the guise of them needing more about my cognition) and her comments on my memory and emotional state that had the most impact and they also got info from my Family Dr. and my recent PET scan,
So here we go again and the case manager made it sound like she was just going to gather info from my two specialists again. Since the spring, both my specialist have been very concerned about my worsening of symptoms that coincide with the sudden and additional inflammation in my lungs/heart and body and thus my meds have been increased. So she needs to connect with them. These flare-ups are not uncommon with this disease however both these specialists also have differing opinions on whether it was the Sarcoid becoming more active or a virus etc and thus the Methotrexate was increased but differing opinions on whether my Prednisone should have been increased which it was via my Cardiologist (and I am thankful for that as I believe it is the Prednisone that is helping to keep me stable). So there are some conflicts here.
Question: should I call my case worker back (she said I could call her if I had any questions) and state that during my initial claim not enough info was gathered from all my health care professionals, so you mentioned contacting my two specialists are you also gong to contact my Family Dr. who is my health care manager and who sees me the most frequently besides my Psychiatrist. Should I also mention that any info needed around my energy level, cognition/emotional state can be best answered by my Psychiatrist/therapist who sees me weekly.

Hi alloys
Thanks so much for your info and sharing your issues. Sounds like you have been thru an awful situation. You can never tell but my caseworker has commented on two different occasions that she does not think I will have to worry about getting continued approval but you know I have heard that before so I don’t trust anything they say. I just want to send lots of Best Wishes to you and your husband and hope things get worked out for you.

Sorry for the misspelling of your name - my computer wants to change it - meant allyoops.

To request an additional information from your doctors they have to pay hundreds of dollars. In my experience they try to reduce the cost by requesting info from the main treating doctor. My case manager only requests clinical records every 3-4 month from the specialist that treats me on a regular basis and not my family doctor.

If I think they need to know more about my treatment I usually fax or email a copy of a report or medical tests to my insurer, then I call and ask them to confirm that it has been added to my case file.

You can gather missing information and fax it to them. I highly doubt they will get those reports from your doctors as they cherry-pick what info to pay for.

Yes-your family Doctor is who every other Specialist sends their reports too. I had to “explain” to GWL that the best source of information is always 1st through the family Doctor who is his health manager.

For some reason Insurance Companies always try to avoid the family doc!!:roll_eyes:

great advice!!! I highly advise after requesting your claim file to obtain any and all medical files that are not included in your claim file and send to your Insurer-proof of receipt-so scanned emails, fax or registered!!

That way if they ever refer you to one of “their” providers or IME’s they have to, or should include, all medical!!

Send them everything-even surgical supply lists and such!

Remember that any receipt for medical records can be claimed on income tax under your medical costs

It is worth a try because if he breached the contract he would not be entitled to benefits. We are also in the alternative claiming that the CPP-D offset should be based on 66 % of his income and not on the 1980 max.

or in the alternative that any offset should be after tax CPP-D amount so that he is not under compensated.

See how it goes…

Thanks for your input. I am just wondering if I should email my caseworker - will have to check and see if I have it. Would there be any harm in just saying that in my initial claim they did not have enough info and needed to connect with my Family Dr. So in our recent conversation you were going to contact my two specialists which is fine but because this is a systemic disease you may want to contact my Family Doctor who is my Health Care Manager and she regularly receives progress reports from all my specialists including my Ophthalmologist and anyone seeing me in their after hour clinics. She is also in contact with my Psychiatrist and assesses me approx every 8 weeks and is reviewing my overall functioning based on her assessment and the reports she receives… Would that be okay to send?

That’s a good idea. You could thank her for her call and let her know that it would be most cost effective to obtain medical information from your family physician as your specialists forward their reports to his/her office.
I would also thank her for letting you know that any decision on your change of definition for benefits would be communicated to you 6 months in advance of the date.