Most teachers will tell you that they love their jobs. For many, education is not just a profession, it is a passion. So, it can be distressing when a teacher is faced with the prospect of a lengthy absence from the classroom due to illness or injury. In those situations, they can turn to the Ontario Teachers Insurance Plan (OTIP), which provides insurance coverage for all unionized members in the province.
OTIP is a not-for-profit insurance provider governed by Ontario’s four teacher associations. The plan offers group and individual insurance coverage, including life, long-term care, dental care, identity theft, retiree health, travel and home and auto plans.
If you are a teacher who is no longer able to fulfill the duties of your job due to injury or illness, OTIP is intended to provide financial security while you recover. But what happens if your claim is denied? A protracted absence can have a devastating effect on your personal life. And a long-term disability (LTD) claim denial makes an unfortunate situation even worse.
OTIP claims have many moving parts. It can have an impact on your pension and other benefits and may also affect future employment. But you don’t have to face an LTD claim alone. We have the expertise and the experience to get you the benefits you deserve to help you rebuild your life and get you back in the classroom where you belong.
Stress Taking an Increasing Toll on Teachers
Illness and physical injury can keep you off the job for months or even years. Lately, there has been a growing number of teachers facing mental health issues that are preventing them from effectively performing their duties.
Teaching can be a difficult job requiring patience, organization, empathy and a great deal of energy. You may face significant stress brought on by such challenges as a shortage of resources, changing curriculum and large class sizes. For many, that stress was further exacerbated by COVID-19.
Indeed, only months into the ongoing coronavirus pandemic, CBC conducted a poll of 10,000 school staff about their experiences in the classroom. Many spoke about the stress of monitoring students to ensure they were following public health guidelines. There were also the long hours required to adapt to teaching to new instruction methods. Fears about their own safety and mental health were among teachers’ top concerns.
The shift between online and in-person learning during the past two years that was necessitated by COVID lockdowns has also taken its toll.
“It feels like we’re building the plane while we’re flying it and the destination keeps changing on us,” one teacher told NPR.org, which also reported that many teachers admit they are eating and drinking more while exercising and sleeping less.
For some teachers, the stress has been debilitating, leading to increased absenteeism. It may be possible to seek accommodations in an attempt to deal with the issue but there are times when filing a long-term disability claim is justified.
Disability and Insurance Policies
The underlying goal of disability insurance is to provide protection in the event that you are no longer able to work or generate income due to an accident, illness or injury. Generally, a disability insurance provider will pay 60 to 85 percent of your total lost income. Often there are limits on the specific amount paid over a specified period.
The definition of a disability can vary between insurance companies and even between different insurance plans from the same insurer. Some disability plans may also require that you take part in a rehabilitation program to help you get back to work.
A long-term disability claim can be complex and failing to follow the rules can negate a claim. For example, because insurers are allowed to offset social security disability insurance payments against long-term disability benefits, your policy may require you to apply for social security insurance benefits. If you don’t apply, your LTD benefits can be terminated.
A claims denial can be devastating but it does not mean you are not entitled to benefits, which is why it is in your best interests to contact an experienced LTD insurance lawyer at Avanessy Giordano LLP. We have the expertise that comes from many years of litigating long-term disability insurance claims. We can cut through the complexities to help you recover the compensation you need and deserve.
How Does OTIP LTD Coverage Work?
Under the terms of the Ontario Teachers Insurance Plan’s long-term disability benefits plan, members are entitled to benefits if they meet the test of disability. The OTIP plan states that you are deemed to be disabled if you are unable to perform the significant duties of your regular assignment due to illness or injury. After the qualifying sick leave period and the following 24 months, you are considered disabled if, because of illness or injury, you are unable to be gainfully employed.
If you are approved, benefits will begin after a required waiting period and are payable as long as you continue to meet the definition of disabled.
Recognizing Mental Health Issues
We all deal with stress. It is part of everyday life. However, chronic stress can be harmful in and of itself and it could eventually manifest itself in depression and anxiety. Typical signs of depression, such as sadness or hopelessness, can be easy to spot but some symptoms may be more difficult to recognize. They include:
- feelings of guilt, worthlessness, and helplessness
- loss of energy or fatigue
- pessimism and hopelessness
- insomnia, or sleeping too much
- irritability or crankiness
- overeating, appetite loss, or weight changes
- lingering digestive issues
- persistent aches, pains, headaches, or cramps
- thoughts of death or suicide, suicidal attempts
- digestive problems that don’t get better, even with treatment
- persistent sad, anxious, or “empty” feelings
- feeling restless or having trouble sitting still
- difficulty concentrating, remembering, or making decisions
- loss of interest or pleasure in hobbies and activities
- increased drug or alcohol use
- disinterest in hobbies
According to the Canadian Mental Health Association (CAMH), one in five people in Canada will experience a mental health problem or illness in any given year. Major depression affects approximately 5.4 percent of this country’s population, with anxiety disorders affecting 4.6 percent of Canadians. The economic cost of mental illnesses to our healthcare and social support system was projected as $79.9 billion in 2021, CAMH reports.
Because stress is an everyday reality, many people simply ignore the symptoms of depression. That can lead to the problem getting worse. If you recognize the signs of depression, you should speak to your doctor. Of course, you may believe you are still well enough to continue on the job. But should you? Some people feel guilty if they have to stop working due to a mental health problem. They may even feel they will be stigmatized if they file a mental health disability claim. These are normal feelings. However, if you are no longer able to functionally perform the essential tasks of your job it is time to seek help. Continuing to work can worsen your condition and further delay your recovery.
You May Benefit From Sick Leave
You may only need to take a short break from work while you deal with your issue. Depending on your policy, you may be eligible to take a short-term sick leave. Details of your entitlement can be found in your collective agreement or you can ask for union or human resources for information and what you need to do to apply.
However, if you find your condition is not improving, you will need to apply for long-term disability. The ability to function is at the forefront of the OTIP LTD definition of disability. Remember, when you are dealing with a mental health claim there are no objective tests such as an X-ray that can help you to prove your case. It will be up to you to provide evidence that your condition is so severe that it has a detrimental effect on your everyday life and ability to work as a teacher. It is also important to note that there are procedures and deadlines with a short-term sick leave or LTD claim. We are here to guide you if you have questions.
Steps to Take When Applying for OTIP LTD Benefits
As a teacher, you can seek the advice of a union representative when filing an LTD claim. Your union can be an invaluable resource. However, those resources have been stretched thin during the coronavirus pandemic and a union rep may not be readily available. What you should remember is that any delay could negatively impact your claim.
If you are considering a long-term disability claim, it is in your best interest to submit your application as soon as you know you will not be able to return to work when your short-term sick leave period ends. You can get claim forms from your union, the insurer or your school board. Contact your union, human resources or OTIP for filing deadline information.
If you are past the end of the sick leave period, you should file your application without delay. A late application will not necessarily be denied, but if the insurer refuses to consider your claim, contact us as soon as you can. We can put our expertise to work for you.
With any LTD claim you should consult with the doctor who is overseeing your treatment to get an attending physician statement. When it comes to an insurance claim, this is one of the most frequently ordered sources of medical background information. Documenting your medical history is essential in any health claim so ask your doctor to provide as much detail as possible. The goal is to make it clear to the insurer that your condition is preventing you from carrying out the specific duties of your job.
One of the biggest reasons an LTD claim is denied or terminated is because the applicant is not receiving the appropriate treatment. When you realize you are facing an issue that compromises your ability to do your job, you need to seek help. It will bolster your LTD claim if you can show that you sought treatment from specialists such as psychotherapists or psychiatrists and are following doctors’ orders.
Keep in mind that it is your job to convince the insurer that your medical condition impairs your ability to function. Provide details that confirm that your symptoms are a barrier preventing you from performing the specific duties of teaching. The attending physician statement should list all disabling conditions and symptoms. Also, provide any specialist consultation reports and test results. This will further support your case. Of course, you should also be keeping copies of your medical history for your records.
Be honest when you are completing your statement. Your information should be consistent with what your doctor has documented. Your claim could be denied if there are inconsistencies. It can be prudent to seek legal advice if you have questions. We are happy to review your claim forms before you submit them to the insurer.
Throughout the process of dealing with a long-term disability claim, you may feel as if you are on trial. It could seem that your case manager does not believe you. But this is how the process works – it is not personal. The same approach is taken with every LTD claim. However, if you believe your case is not being fairly assessed it is in your best interest to seek legal advice.
What Happens When Your Long-term Disability Claim has been Denied?
It can be frustrating and disheartening when your LTD claim has been denied or your benefits have been terminated. You may not be able to continue to afford the treatment you need to get back in the classroom. Termination or denial does not mean you should give up. You have the right to appeal. However, for those dealing with severe depression, it may be difficult to continue the fight. It could also set your recovery process back. When you are dealing with mental health issues, your focus should be on getting better, not dealing with red tape.
An OTIP disability service representative is available to assist with your appeal at no extra cost and some teachers find this can be helpful. However, it should be noted that most appeals fail and will be heard by the same insurer that terminated your benefits or denied your claim. There are circumstances where appeals are successful. Generally, that happens when there is new compelling evidence of disability. At Ava Gio, we are in your corner and we know how to file an appeal on your behalf.
You should also be aware that the clock starts running from the date of your denial. You have a limited time to send an appeal letter outlining why your claim should be reconsidered. This date will be outlined in your decision letter. General information on the timeline can also be found in your group plan provisions.
You will be asked why your claim should be reconsidered and given the opportunity to submit new or additional medical information that can help your case.
The disability specialist may approve your appeal or send it to the appeals committee. If you fail to win your appeal you have the option of binding arbitration through your union grievance process. This can be time-consuming and unions are not always able to take on every case. As well, unions evaluate your claim based on their own criteria and could decide not to arbitrate on your behalf.
Litigation Maybe Your Best Option
Although you may not be aware of it, you are not required to appeal or grieve the denial or termination of your OTIP long-term disability claim. You can take your case to court. You should keep in mind that in Ontario you have two years from the date of the first denial to start legal action and the limitation period is not suspended while you are appealing your claim.
Litigation can be stressful so it is important to select a law firm with a focus on long-term disability claims. Your case is unique and you deserve a lawyer who understands what you are going through.
Get Ava Gio in Your Corner
The OTIP long-term disability benefits plan is a highly specialized policy so it only makes sense to get advice from lawyers who have extensive experience in dealing with insurance companies. We will meet with you to review your claim, explain the process and suggest a plan of attack. Our lawyers understand the Ontario Teachers Insurance Plan and know your issues. We will gather sufficient evidence to prove that your disability claim meets the relevant tests for disability in accordance with the disability insurance policy wording. If your application for long-term disability benefits has been denied or if your benefits have been terminated, contact us for a free consultation.