Insured with Canada Life Assurance Company
Policy No. 335645 – Division 10
Canada Life Assurance Company
Langley Disability Management Office
2nd Floor, 8700 – 200 Street
Langley, BC V2Y 0G4
General Office Number: 604-455-2700
Toll-Free Number: 1-877-262-0749
Fax Number: 1-844-569-3131
Email Address: Langley.firstname.lastname@example.org
Disability Claims Process – Summary
Disability comes in degrees. At any given time, there may be employees on the job who are at risk for absences and disability. You could be coping with the demands of teenagers or aging parents, trying to manage a medical condition, etc. Other employees could be attempting to return to their normal or work routine after an absence. Any of these situations could escalate into a disability.
The focus of the disability office is on creating opportunities to support recovery and the ability to enable you to return to work.
Employees on short-term disability (STD):
Once an employee is on short-term disability, the focus shifts to recovery and return. Statistics show the longer an employee remains on disability, the less likely they may return to work. Providing the right support for the right problem early on is critical.
Employees on long-term disability (LTD):
Employees facing a serious long-term disability need the most extensive level of support and intervention to realize their potential. By using the same Case Manager throughout, the disability office provides a seamless transition from Short to Long-term Disability and effective support for our employees.
· Health & Wellness Library – employees who are participating in our Extended Health or Dental benefits can access a wealth of information to help manage your health, through the Canada Life website for plan members (http://groupnet.greatwestlife.com).
· Medical Coordination – provides medical support and expertise from the first report of illness or injury, continuing through treatment. It includes coordinating information between the employees and physician, confirming diagnoses and treatment plans, and faster access to specialists.
· Vocational Rehabilitation, Consulting – provides return-to-work planning, education and job search assistance and helps employees adjust on a personal and vocational level.
· Exchange – a unique communication process that uses facilitated meetings to bring the employee and the employer together early, to work through issues affecting the employer’s return to work.
· STD and LTD Case Management – progressive case management services designed to ensure claims are handed according to the terms of your plan.
· At-Work Services – provides vocational or medical rehabilitation and related services while the individual is still at work, to help the employee remain on the job.
Every claim submitted to Great-West Life will be unique, but will follow through a management approach that offers the following key value points:
· Timely information gathering and initial assessment
· A team approach to management, quarterbacked by a single Case Manager
· Regional claim management
· Vocational Rehabilitation consultants who focus on the no-medical elements of case management
· Medical Coordinators who can add value where medical attention or interpretation is a barrier to return to work
At the heart of the management team is the Case Manager. This person is responsible for a claim from inception until the employee returns to work, or otherwise is no longer eligible for benefits.
Gathering information quickly and making an initial assessment early is critical. For straightforward claims, the value the disability office looks to add is:
1. To get the employee their income as soon as possible
2. To minimize the investment in resolving the claim by avoiding the collection and expense of unnecessary reports and documentation
More complex claims can pull in the expertise of specialists to achieve and return to work goal. In most of these cases, early telephone contact will be established with the employee to get a good first-hand understanding of the disability, and to set the stage for the process. With these cases, the goal is to apply more resources to the management of the claim where there is good expectation an early return to work may be achieved.
The two primary resources the Case Manager may call upon are their Vocational Rehabilitation consultants and their Medical Coordinators.
All of the Case Managers are trained to recognize situations where employees are suitable candidates for return to work programs. The Case Manager would then engage one of their Vocational Rehabilitation Consultants who will work together with the employee, employer, and the attending physician to implement and monitor the program.
Great-West’s Medical Coordinators are qualified professionals with a medical background and several years of experience managing disabilities. The expertise they bring is important since prolonged waits to access a specialist can otherwise cause unnecessary frustration and uncertainty, as well as delay treatment and jeopardize a successful return to work.
Some of the other resources the Case Manager may use throughout the management of a claim could include:
· On-line access to proprietary disability management manuals and medical investigation manuals
· Local Medical Consultants, whose primary function is to assist with the interpretation of medical files
· Independent Medical Examiners who may be used where the medical information may not be fully available
· In extreme and generally rare occasions, surveillance and fraud investigation tools are available.
Finally, as a part of the financial management of a claim, the disability office will correspond with the employee concerning their application for other income benefits, such as C/QPP and Workers Compensation.
Initial Claim Review:
Before a claim decision can be made, the Case Manager must review the claim to gain insight into its complexity and validity. This step in the process includes gathering information about the claim and verifying the plan parameters and assessment criteria.
The first pieces of information gathered by the Case Manager will be the claim form and the physician’s statement. If the documentation is straightforward and complete, then the claim decision can be made quickly and accurately. On the other hand, if the information is not straightforward or incomplete, then it is examined more closely.
Canada Life may call the employee to obtain information about their condition and treatment. Then, if additional information is needed, more specific questions can be directed to the employee’s physician. Calling the employee establishes early and personal contact, and sets the stage for potential rehabilitation discussions.
Short-term Disability (STD)
The Case Manager must assess the plan specific criteria before making a decision. This entails reviewing eligibility requirements, plan limitations, and any further plan specific criteria within the CISVA Group Policy Contract. Once these plan parameters are verified, then the disability office can accurately assess the claim against the contractual provisions of the CISVA plan.
Claim Assessment & Decision:
Once the claim has been initially reviewed, the Case Manager can then assess the claim and determines if it satisfies the plan provision. If the claim is accepted the management of the claim begins. If the claim is declined, then the employee is advised concerning the reasons for the declination. Information is also provided on additional medical facts needed for further review or on how to appeal the decision should the employee disagree with the discussion.
In making an initial assessment of a claim, the disability office reviews all of the information gathered pertaining to the claim. This initial assessment will give direction to the claim, and assist in determining the plan for further handling of the claim.
· Maximize Return on Investment
In order to maximize return on investment, the Case Manager must make sure that straight-forward claims are paid accordingly, and only investigate the more complex claims further.
· Plan provisions
In order for a disability claim to be accepted, the disability must be covered in the CISVA plan provisions; therefore, the Case Manager must check the plan provisions before moving forward with the claim assessment.
· Limitations and Exclusions
Limitations are provisions that may result in a claim terminating (temporarily or permanently) if certain criteria have not been satisfied. Exclusions, on the other hand, are initial requirements that, if not met will result in a claim being declined (i.e. a pre-existing condition).
Decision-Making Tools Available:
The Case Manager uses many tools when making a decision on a claim. These tools are important in making the right decision in a timely matter.
At Canada Life’s disability offices, they have created proprietary manuals to assist in the assessment and management of disability claims.
· Normal Convalescence Periods
Industry recognized reference materials are used in order to establish a normal recovery period for disabilities. These reference materials, along with the knowledge of Medical Coordinators and Medical Board Consultants, allow the disability office to determine duration period information. This also enables the Case Manager to make appropriate plans for the employee to return to work.
The Case Manager determines when it is appropriate to use the services of a Medical Consultant. The medical consultant is used to interpret the medical test results and other clinical information. The Case Manager then compares the medical restrictions to the employee’s job abilities to assess if the employee is medically able to do their job.
If a claim is declined or disputed, the employee has the right to an appeal; this right to appeal is outlined to the employee in the decision letter. The review process requires the employee to submit additional information. The employee may also appeal by providing detailed reasons why the claim should be reassessed. Upon receipt of the additional information, the employee will be provided with the results of our reassessment.
Disability Management (Accepted Claims):
The management of a disability claim is the most detailed part of the disability claim process. In order to manage such detailed claims, Case Managers frequently use the following tools:
· Medical Coordination
The overall objectives to the management of a claim are to:
1. Maximize non-medical management via Vocational Rehabilitation Consultants
2. include Vocational Rehabilitation and Medical Coordination in detailed claims
3. Have the Case Manager act as the “Gate Keeper”, responsible for the management of the claim from inception until the return to work
4. use other supplemental disability tools to help manage the claim
Disability Management Tools:
Case Managers can use many different tools in order to manage a disability claim. These tools are in place for the Case Manager to get the employee back to work as soon as possible. The main disability management tools are as follows:
· Vocational Rehabilitation Referral
Vocational Rehabilitation Consultants are internal specialists that focus on the return to work planning and management.
· Medical Coordination
Canada Life’s Medical Coordinators are qualified professionals with a medical background and several years of experience in managing disabilities. The expertise brought is important since prolonged waits to access a specialist can otherwise cause unnecessary frustration and uncertainty, as well as delay treatment and jeopardize a successful return to work.
Ongoing Medical Coordination supports the treatment plan by focusing on realistic return-to-work options. Throughout the duration of the disability, the disability office maintains close contact with the employee, physician(s), and the employer to coordinate medical care and return to work planning.
· Disability Reviews
Disabilities will be reviewed at various times during the claim. The timing depends on the medical condition and the treatment plan. The disability office may contact the employee by phone to determine the appropriate timing of these reviews. This personal approach to the claim review keeps the employee and the Case Manager in constant communication throughout the duration of the claim.
· Medical Consultants
A Medical Consultant may be used at any time in the assessment of a claim. Their expertise can assist in the interpretation of test results, reviewing current treatment plans, or other clinical information. Referral to a Medical Consultant may also be an appropriate approach when trying to bring a new treatment direction to the management of a claim. Medical Consultants can provide recommendations in the areas of medication and future treatment that may be more comprehensive than those available from a basic assessment.
· Independent Medical Exam
Great-West arranges an Independent Medical Examiner (IME) when the situation is appropriate and the cost of an examination is warranted.
· Functional Capacities Evaluation
Canada Life uses Functional Capacity Evaluations to test for abilities in different tasks. This evaluation, often conducted by occupational therapists, verifies the employees’ abilities through medical exams and physician tests.
· Fraud Investigation
Great-West has policies and procedures for the identification and investigation of potentially fraudulent claims. Case Managers are in the best position to identify possible fraudulent claims and cases of abuse. Information that does not appear consistent or logical may provide an initial warning of a possible fraudulent claim.
· Activity Investigation
Activity investigations using third party investigators are not a routine part of disability claim management. However, they can be important in cases where the medical information may support the employee’s entitlement to benefits, but the degree of disability is in question. Under these circumstances, an investigation is initiated in order to determine whether the employee’s observable daily activities correspond with the degree of disability claimed. An investigation may also be warranted in response to suggestions that the employee is engaged in other employment, and thus earning an income that should be offset from the disability benefit.
Experience has shown that early initiation of rehabilitation is an integral part of effective comprehensive disability management; therefore the possibility of rehabilitation is immediately considered in claim assessment. If appropriate, a telephone interview will be conducted to assist in developing rehabilitation plans and programs for the employees.
Seamless STD/LTD transition:
The disability office strives for a seamless disability approach allowing for an easier transition between Short Term and Long Term disability benefits. The assigned Case Manager is responsible for referrals to Medical Coordination and Vocational Rehabilitation, as well as the claim assessment. Individual claim attention provides consistent and proactive management of the claim and a personal touch in what is often a difficult time for the employee.
Alternate sources of income, such as CPP, WCB, and auto insurance, act as significant sources of savings to disability benefits. The disability office ensures that any employee who may be entitled to these alternate insurance benefits is notified of their potential entitlement.
Canada Life advises the following individuals to pursue a claim with CPP benefits:
People with degenerative, chronic or terminal conditions.
Where there is no indication that a person is medically capable of any work (ie. If it appears improvement is unlikely, benefits may continue until age 65),
Or where the person is over age 60 and not expected to recover from their medical condition and be able to perform any work.
In these situations, benefits could continue beyond the change in definition point, so it is appropriate to advise employees to apply for these CPP benefits.
Canada Life will request a completed CPP option form, a CPP assignment form, and a copy of the CPP/QPP confirmation of application from the employee. The disability office continually assesses claims each time new information is received to determine if the employee should be pursuing a claim with CPP.
The possibility of auto insurance benefits is considered whenever disability is a result of a motor vehicle accident. If alternate benefits are denied, the disability office will assume liability provided other contract requirements have been satisfied.
Once a claim has been approved, the employee is entitled to disability benefits. The following point needs to be taken into consideration to claim payments:
Methods of payment:
Canada Life currently supports two methods of payment – Direct Deposit and Cheque Payment. In order to process an electronic fund transfer, Canada Life requires bank identification and account number for each disability claimant. If the employee chooses cheque payment, the disability office sends the cheque directly to the employee.
Termination & Appeal:
Termination of the claim is the final step in the disability claims process. A claim is considered to be terminated once an employee has returned to work or not longer meets the CISVA plan provisions. For those employees who have been in receipt of Long Term Disability benefits for more than two years, the employee will receive 30 days notice prior to the termination of benefits for those employees whose Long Term Disability benefits are terminating due to a change in the definition of disability. The disability office will advise an employee of their decision as early as possible. If a claimant feels that their claim has been terminated prematurely, they are entitled to an appeal.