Long-Term Income Protection (OPS)

If you are a regular employee and unable to attend work because of illness or injury for longer than six months, the Employer’s Long-Term Income Protection (LTIP) program could provide you with long-term salary protection.

Periods of less than six months are usually covered by the Short-Term Sickness Plan (STSP).

The LTIP program is offered by your Employer and administered by insurer Canada Life. As such, AMAPCEO does not have a hand in shaping the policy. However, your union has negotiated entitlements above and beyond those outlined in the LTIP program. These improvements are an important advantage of being a unionized professional.

Eligibility

Permanent ("regular") employees

• Full-time employees are eligible to apply for LTIP.
• Part-time employees are eligible to apply for LTIP and if successful, will receive income protection on a pro-rated basis.
• You must:
  • be totally disabled (see the definition below), and
  • be under the personal treatment of a physician during the entire period of disability.
• You are no longer eligible to apply for LTIP on:
  • the day you reach age 64 years and 6 months, or the day you retire, whichever is earlier;
  • the last day of the month in which you cease employment by resignation, retirement, or termination; or
  • the date you joined the armed forces of any country on a full-time basis.

Temporary, fixed-term, or contract employees

If you are a temporary, fixed-term, or contract employee and you need to be out of the office due to illness, please seek the assistance of an AMAPCEO Workplace Representative.

The Long-Term Income Protection (LTIP) plan

If you:

• are absent from work due to illness or injury for longer than six months; and
• the insurer approves your LTIP application,

you will receive 66 2/3% of your basic gross earnings from your Employer through the insurer. This will include any retroactive changes to your salary, including across-the-board increases and any unpaid merit increases.

While on LTIP, your health benefits coverage and pension contributions will be maintained as though you were still at work. All deductions and contributions will be made as though you were receiving your regular salary. If you have opted for supplementary life insurance coverage, it will continue, though premiums will be waived after nine months’ absence from work or your first day of LTIP.

The LTIP program is provided by your Employer and administered through the insurer. For details, please consult the information provided by your Employer on the OPS Intranet or contact the insurer.

Absences from work due to illness or injury that are shorter than six months are usually covered under the Short-Term Sickness Plan (STSP) or a combination of other paid credits.

How to apply for LTIP

When you are absent from work for three months or longer, your Employer will send you a package to begin the LTIP application process.

If you do not receive your LTIP application package after three months of absence, you should request one through your Human Resources Advisor, your supervisor, or Ontario Shared Services (OSS).

Completing your application

The application package will ask you to:

1. Complete an Employee Statement. The Statement is designed to provide the insurer as many details about your claim as possible. Do not limit your responses to the space provided on the form. You can add additional pages to provide the insurer will a more fulsome response. Contact an AMAPCEO Workplace Representative if you need assistance.

2. Send your Employee Statement directly to the insurer.

3. Notify your manager or another Employer representative that you have submitted your Employee Statement. Your Employer is not entitled to see a copy of your LTIP application. This will prompt your Employer to submit their Employer’s Statement to the insurer within two weeks.

4. Ask your doctor(s) to complete the Attending Physician’s Statement (APS) form in detail. They may attach documents and additional pages (e.g., clinical notes, lab reports, reports from other medical practitioners) to the APS form. To avoid complications or delays in processing your claim, ensure that each of your treating practitioners have fully submitted as much information as possible. Costs for completing APS forms will be covered or partially covered by your Ministry. Your Employer is not entitled to see a copy of your completed APS forms.

Once the insurer has received your Employee Statement, the Employer’s Statement, and any completed APS forms, they will assess your claim. While your claim is being assessed, the insurer may request a medical assessment (usually from a specialist) at its own expense.

Receiving your assessment

The insurer will send you a letter outlining their decision and their reasoning. They will also tell your Employer if your application was approved or denied.

• If your claim is approved, you will begin receiving benefits under the LTIP program after six months’ continuous absence from work.
• If your claim is denied, the insurer will advise you of your right to appeal, at which time you can provide any new or expanded medical information or explanation of your issues.

If you provide new or expanded medical information to the insurer and they still do not approve your claim:

• contact the AMAPCEO office right away.

Assessing your claim

Insurers will look closely at the type and treatment you receive. They will look for industry best practices of medical care and your active engagement on the issue. If they do not see these, they will most likely deny or terminate your claim.

Insurers do not place much weight on your Employee Statement when assessing your claim. Instead, they base their decisions on the APS forms from your physician(s). As a result, if your day-to-day reality as expressed in your Employee Statement doesn’t match with the completed APS forms, the insurers will rely on the latter.

The insurer will assess your claim for LTIP during two different periods of time.

During the first 30 months (the first six months of your absence from work and the 24 months following):

• this is called the “Own Occupation Period,” and the insurer will assess if you are “wholly and continuously disabled by illness (including a mental disorder) or accidental injury” from performing the essential duties of your own occupation.

After 30 months:

• this is called the “Any Occupation Period,” and the insurer will assess if you are unable to perform the essential duties of any occupation for which you are reasonably fitted by education, training, or experience. During this period, the insurer will not consider the availability of such work.

Common reasons for denial

Below are four common reasons why an insurer might deny or terminate an LTIP claim:

If you are not under the care of a specialist

Your Employer’s LTIP policy requires you to be under the regular care of a physician during the six-month waiting period and during the claim period.

The insurer will place more weight on medical care received from a specialist.

If your appointments are considered irregular

You should attempt to schedule and maintain regular appointments with your physician. Avoid sporadic or erratic appointments as much as possible.

If your treatment is considered insufficient

Insurers will also examine the type of treatment you receive and consider it against the most common treatments it considers to be best practices. The further your claim deviates from the norm or these best practices, the more likely the insurer will scrutinize your treatment.

Unfortunately, sometimes, you may receive a level of care below what the insurer expects. If your physician is providing you with a level of care that deviates from what the insurer considers a “best practice”, the insurer may deny or terminate the claim. It is important that you advocate for yourself when consulting with your physician.

If your documentation is considered incomplete

You may have a wonderful, fully accredited physician, and completely comply with their treatment, and the insurer may still deny or terminate your claim. It could be that the insurer feels your medical documentation is lacking or incomplete.

If this is the case, you may wish to appeal, at which time you can provide any new or expanded medical information or explanation of your issues.

Your right to appeal

If your LTIP claim is denied and you are unable to resolve it with the insurer, you have the option to ask AMAPCEO to file an appeal on your behalf at the Joint Benefits Review Committee (JBRC), in accordance with Article 32 of your Collective Agreement. Please contact the AMAPCEO office right away.

Disability due to mental health illness

Mental health illness is one of the most common reasons for disability from the workplace.

Insurers have taken additional measures to manage the increase in mental health claims, including creating specific internal policies and procedures for handling mental health disability-related claims. In other words, these claims get special attention from insurers.

For example, a common tactic for an insurer is to argue the illness is the result of a challenging work relationship or a toxic work environment, which is not covered by the policy. They reason that if the employee were not in that specific environment, then the employee would not be totally disabled.

Below are some of the insurer’s standard expectations for a LTIP claim for a mental health illness:

• You are under the care of a psychiatrist or psychologist.
  • The insurer reasons that if your illness is sufficiently serious to take you out of the workplace, then you ought to be under the care of a specialist.
  • While family physicians can and do treat mental health illnesses, few provide the type of care and level of care necessary to meet the insurer’s expectations.
  • We recommend you confirm your treating physician’s credentials to ensure that their care will be accepted by the insurer when assessing your claim. If you are not sure, contact the AMAPCEO office for assistance.
  • If your claim is for mental health illness and is longer than 30 months (going into the “Any Occupation Period” described above), you must be under the care of a physician certified in psychiatry or neurology.
• You have regular appointments with your physician.
• You are being treated with a combination of medication and regular psychiatric therapy.

If you have questions or need assistance

Please contact an AMAPCEO Workplace Representative in your District. They do not have to be in your Ministry.

Workplace Representatives are trained union members who have volunteered to confidentially assist members like you in the workplace. They should be your first point of contact in seeking information and representation with an issue at work.

Your Workplace Representative may ask you to use the union’s secure web-based system, RADAR, to provide details about your situation. RADAR will help you and your Workplace Representative keep track of things without the privacy concerns that could come from using the Employer’s email system.