Requesting master copy


#1

Wondering, reading my NEB’s group plan it says I can request a copy of the master policy. I’m wondering if doing this will tip them off that I am preparing for taking my claim farther if I receive a rejection to continue on Ltd. I have been on Ltd and my 2 years is up in September. I have completed the functional capabilities they requested last month and because my plan switches to " any occupation" (end of September) I am becoming very concerned as my spinal injury limits me to being unable to sit, stand or walk for more then about 10 minutes before I need to lay down. Is this a good time to get lawyer? There is no cure, only bandages and progression. Does law suite have to be started before end of 24 months?


#2

You typically have at least 2 years to file a claim after they deny you benefits.
There is no harm in requesting the master policy-I am not a lawyer but believe you should as it is what governs your claim.
Did you get a copy of the Functional exam-that would give you an indication of where your claim is heading into the 2 year mark?
Any mention from them for applying for CPP-D benefits?


#3

Does the insurance company always request a functional exam?


#4

https://resolutelegal.ca/functional-capacity-evaluation-explained/

No they do not always request-it is quite expensive.


#5

My functional ability varies quite a bit on different days and different hours on the same day.


#6

Thank you Allyoop’s, I received an email from the person putting the report together requesting x-ray reports so she could finish and submit to insurer.
Thing is, almost 6 years ago I had a fall and suffered a broken bone, I never recovered that however did go back to work. It’s hard to tie that fall to this injury. I think insurance is going to try, however compensation Dr’s say that break and this injury are not related therefore refused that claim. At this time there is no mention to apply CPP_D, is this a good time to do that?


#7

You should also offer to pay for photo copying and offer to pick up a copy yourself. You have a right to a copy and copies of medical records that they have.
If you have a doctor that supports you applying for CPP-D then you should. If the physiotherapist refuses to provide you a copy, read the section on who owns your medical records.
That report could hurt you or help you for CPP-D.

Be really, really nice when asking. Don’t be pushy, but under all privacy laws you are allowed a copy.


#8

I too requested a copy of my group master policy. In writing on March 30th. I have yet to receive it and was told last Monday it was mailed out. Still nothing. I have received a letter my case manager referenced during that conversation on Monday last.
The letter states that there will be a change in definition come August 25th, the 2year mark. And by their internal medical review and my case manager’s learned opinion, that I am not able to return to work in any occupation capacity. And Manulife will continue monthly LTD payments in good faith. They will, from time to time request updates from myself and doctors.
The case manager, also said in the letter that I will have a rehab specialist contacting me to discuss the issues with access to treatment. My policy has no mental health coverage. I am off with PTSD, Bipolar II, Anxiety and Panic, Intermittent explosive disorder (uncontrolled rapid cycling anger). And there are over years long waiting lists for OHIP treatment.


#9

Sounds like a good experience. But how do you get benefits if they don’t cover mental health?


#10

I don’t other than drug therapy. And I’m on a waiting list for OHIP funded Psychotherapy. Policy only covers income replacement


#11

Have you ever looked at what is required to be a case manger! To be a claims examiner at GWL you need a grade 12 education and a keen interest in investigation. My friend was a waitress and hair dresser-she has family that works at Workers Comp and now she is a claim manager, deciding to approve or deny medical claims.


#12

Follow the money! The goal of a rehab consultant is to get you off claim. I would guess some activation therapy paired with psychotherapy with the goal of restoring you to employ-ability!
This can be very helpful but can also be very harmful. If you are part of a Union I would ask to have a rep with you when you meet the rehab consultant.


#13

Derek’s LTD covers income replacement, but he does not have group benefits for a psychologist. In most group plans there are rehabilitation benefits. Your insurer will only offer if the rehab consultant can estimate that it will save money on the claim in the long run if the Insurer pays for services.


#14

I was being sarcastic hahahha


#15

There is no harm in trying to get a copy of your insurance policy. It is understandable that you worry about not doing things that my be a red flag for the insurance company, but in my experience such actions by you have no impact on their decision. They have likely decided what they are going to do.

The time to bring a lawsuit varies form province to province and from policy to policy. You would have at least 1 year from the date of denial of payments.

If you are cut off at the 2 year mark you should get a confidential legal opinion on your best course of action. You may or may not make sense for you to do an internal appeal with the insurance company before you file a lawsuit.


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 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. Answers from lawyer moderators are provided for informational purposes only, you should consult with your own legal counsel before taking any action that could affect your rights or legal obligations.


#16

This is exactly why Functional Capacity Evlauations are not reliable. As a former occupational therapist I love to pick apart FCEs and FAEs done on my clients. There are often many mistakes made by the person giving the examination that also make them invalid.


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 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. Answers from lawyer moderators are provided for informational purposes only, you should consult with your own legal counsel before taking any action that could affect your rights or legal obligations.


#17

Did you get a complete copy of the policy?


#18

Yes. I finally got a copy of the Master Policy. It Cleary defines total disability as the inability to perform the duties of any job. Very vague. However they have said due to internal review they have determined I am unable to return to work in any capacity yet. I have a phone meeting scheduled with their rehab specialist this coming Wednesday. I have had a meds set back with an increase in dosage of a mood stabilizer and a potential new diagnosis not confirmed before.
Borderline personality disorder. Explains the lack of impulse control.
Still have zero treatment other than meds and a counsellor once every 6 to 8 weeks. I was just reviewing their independent medical report, which states that without treatment. My symptoms will only get worse.
I told rehab specialist that if all they’re offering is 6 to 8 counselling sessions after stalling for 2 years to think again. Because it won’t be enough I’ve already done that. Sorry I am bitter.


#19

Supreme Court says:
The test of total disability is satisfied when the circumstances are such that a reasonable man would recognize that he should not engage in certain activity even though he literally is not physically unable to do so. In other words, total disability does not mean absolute physical inability to transact any kind of business pertaining to one’s occupation, but rather that there is a total disability if the insured’s injuries are such that common care and prudence require him to desist from his business or occupation in order to effectuate a cure; hence, if the condition of the insured is such that in order to effect a cure or prolongation of life, common care and prudence will require that he cease work, he is totally disabled within the meaning of health or accident insurance policies.


#20

Be careful that they don’t say you are not being compliant. Any rehab offered make sure you take to your Doctor for approval/review before starting