Plan member’s guide to submitting a Disability Insurance claim

The Disability Insurance (DI) Plan is an insurance plan available to employees of the federal public service, including those at the National Research Council who are represented by the RCEA. The DI Plan is mandatory for all full-time employees hired after November 1970, and for part-time employees hired after September, 1982. Term employees hired on less than a six-month term must join the plan at the six-month point if their term is renewed.

The DI Plan is administered by Sun Life Assurance Company of Canada (Sun Life) and provides benefits to eligible employees who become “totally disabled” as a result of illness or injury. “Totally disabled” means that you have an illness or injury that prevents you from performing each and every duty of your regular occupation.

This guide is designed to help you through the claim submission process and to answer any initial questions you may have with respect to filing a claim for DI benefits. Some key terms are hyperlinked in this document to make it easy for you to understand how to claim DI benefits.

To further assist you, a pamphlet entitled ”A Step-by-step Guide to the Disability Insurance Plan Claim Process”, will be sent to you by Sun Life as soon as they receive your DI claim.

Where there is a discrepancy between this Guide and the Disability Insurance (DI) Plan Document, the terms of the plan will prevail. This Guide is meant to assist RCEA members and is not binding on Sun Life or the NRC.

DI Benefits

Your DI benefits are a monthly payment equal to 70% of your monthly salary.  The following are some important rules about this payment:

  • This amount is taxable;
  • The amount is only payable after 13 continuous weeks of total disability or when your paid sick leave is exhausted, whichever is later;
  • Benefits are reduced by your other sources of income, such as income from other employment;
  • Your benefits are increased to a maximum of 3% annually to reflect cost of living increases;
  • You are also eligible to participate in rehabilitation programs for up to 24 months. Earnings from rehabilitation programs are not deducted from your DI benefits unless they exceed 100% of your pre-disability income. Please see a more thorough description of rehabilitation benefits below;
  • If you suffer from a pre-existing condition, you may not be eligible for benefits if your  disability commences within the first 12 months after you become eligible for coverage
  • No benefits payable beyond age 65

 

Reporting your absence

If you become disabled and your disability is expected to be prolonged beyond the 13-week elimination period or the exhaustion of your sick leave, whichever is later, you should notify NRC’s Pay and Benefits Services. You are also responsible for reporting your ongoing absence to your employer.

To apply for Disability Insurance (DI) benefits, your DI claim forms should be completed and forwarded along with all supporting medical evidence to Sun Life, ideally at least eight weeks prior to the end of your elimination period, but no later than 90 days after the end of your elimination period. You are responsible for providing Sun Life with sufficient medical proof of total disability.

The Disability Insurance (DI) package contains three forms:

  • Part 1 – Employee’s Medical Information, to be completed by the employee;
  • Part 2 – Attending Physician’s Statement, which you take to your doctor to complete and fax to Sun Life. Note: Your doctor may charge a fee to complete this form. If so, you will be responsible for paying that fee.

 

  1. Completing the Employee’s Statement

This statement provides Sun Life with information about your condition, your general medical history, your expected sources of income and benefits while you’re on leave, and your expected return to work date.

  • Be sure to answer all the questions in full to avoid delays when Sun Life assesses your absence, and include a detailed job description and resume, including previous job experience and education history. (You may attach extra paper to the form if you need more space.)
  • Be sure that all dates provided (date you were first unable to work, date of accident, etc.) are correct since they are essential to Sun Life’s assessment.
  • Remember to complete the “Automatic deposit of your disability payments” section. If your claim is approved, your payments will be deposited directly into your bank account. For chequing accounts, a personalized VOID cheque will be required.
  • Please read and sign the Declaration and Authorization portion of the form, which allows Sun Life to exchange information with your doctor and any other health care professionals who are involved in your care. Also, please sign Part 1 of the Attending Physician’s Statement before giving the form to your physician to complete.
  • The member will send this form directly to Sun Life once it is completed. Do not rely on the NRC to submit this form.

 

  1. Have your physician complete the Attending Physician’s Statement

This statement provides Sun Life with specific medical information about your condition and your expected recovery.

  • The Attending Physician’s Statement must show a clear diagnosis and prognosis for your condition. (This doctor can be your family doctor, a doctor at a walk-in clinic, a specialist, etc. – or a medical doctor licensed to practice medicine who has treated you for your condition.)
  • If your doctor conducts tests, all of the findings must be included on or with the Statement.
  • If you have seen a specialist for your condition, be sure to have your Attending Physician send copies of all consultation and clinical notes with the Statement. (Often, Sun Life must follow up to request these documents which can delay the assessment of your claim).

Note: Do not change or write anything on the Attending Physician’s Statement. Any changes to the Statement must be initialed by your doctor.

  1. Sending your Disability Insurance claim package
  • Follow up with your doctor and NRC’s Pay and Benefits Services to confirm they have completed, signed and faxed their Statement forms to Sun Life. Your claim cannot be assessed until all three forms have been received; from you, your employer and your doctor.
  • It is recommended that you submit the completed claim forms to Sun Life at least eight weeks prior to the end of your elimination period. This provides Sun Life with sufficient time to review your claim and obtain any additional information required in order to complete the assessment for benefits. You can file your forms even if the employer’s form has not been submitted yet, but your claim is not complete without the employer’s form.
  • If there is a delay in getting this information to Sun Life, it is important to note that there are time limits for submitting claims under the Disability Insurance (DI) contract. Sun Life must receive your completed statements no later than 90 days after the end of the elimination period or exhaustion of your sick leave, whichever is later. If you fail to abide by this time limit, you may not be entitled to some or all benefit payments where the delay impedes Sun Life’s ability to assess your claim.
  • Faxing your forms, using Sun Life’s secured fax number, is the fastest way to send your forms. It is also convenient as you do not need to mail information that you send by fax, so you will have the originals for your records.

 
Be sure your Certificate Number (begins with the letters CG) is clearly indicated on your Employee’s Statement and your portion of the Attending Physician’s Statement before faxing/mailing. If you do not know your Certificate Number, please contact NRC’s Pay and Benefits services, who will be able to provide this information.

Your information is supposed to be confidential

Sun Life has stated that it is committed to respecting your privacy and protecting your personal information. The information you provide for your Disability Insurance (DI) claim is highly protected and treated with sensitivity. Your personal and medical information should not be disclosed to other parties, including your employer, without your written consent.

How long will benefit payments last?

For the first 24 months, as long as you are disabled from working in your own job.

After 24 months, DI plan members will continue being paid benefits when they can provide medical proof that their disabling condition prevents them from doing a “commensurate occupation” for which they are reasonably qualified by education, training or experience.

According to the DI policy, “commensurate occupation” means a job for which the rate of pay is not less than 66 2/3% of the current salary for your regular job.

If you satisfy Sun Life’s medical consultants that you meet the definition of total disability in the DI policy, you are eligible for DI benefits up to age 65. Again you will need concrete and convincing medical evidence.

Sun Life will stop paying benefits if and when your medical situation improves and you no longer fit the DI plan’s definition of “total disability”.

What about rehabilitation programs?

Sometimes your health situation may enable you to participate in a rehabilitation program, which means re-training or new work. Normally you must request approval in writing from Sun Life during the first 24 months that you receive benefits. If you have received DI benefits for more than 24 months, ask Sun Life’s Rehabilitation Unit for counselling and help.

Always be clear that you are ready to participate in any program that respects your medical limitations. You have options like gradual return to work (for example – half days for the first month), or doing some but not all tasks. No one wants to make you sick again. On the other hand, you may be cut off benefits if you do not cooperate.

The DI plan also permits you to participate in rehabilitative employment. Wages from any rehabilitative employment are not cut out of your DI payment until your DI plus wages adds up to more than 100% of your old job.

What do I do if my claim is rejected?

Your claim is first processed by a claims adjuster at Sun Life. If the information you give is not sufficient to enable Sun Life to make a decision on the claim, they will request more specific and detailed information. Keep copies of everything you send them. If you give sufficient evidence, the claim is approved. If not, the claim is denied.

If your claim is denied, Sun Life will ask you for more documentation. If, after another review, the claim is still refused and you disagree with that decision, you can ask Sun Life’s Disability Management Unit to review your case. This is called an “appeal.” This committee, made up of senior claims analysts, may overturn a claims adjuster’s earlier decision.

To appeal, send a letter to:

Disability Management Unit
Group Claims Control Department
Sun Life Assurance Company of Canada
PO Box 12500, Station CV
Montreal, Quebec  H3C 5T6

Visit their website for phone numbers and other contact information.