Many of us struggle to keep working when we are sick or injured. Employers know this. 

They have created programs to help their employees. We are talking about the best health insurance. In North America, companies do offer such benefits to their employees. If you have questions about disability Insurance, contact your company’s HR officer.

Insurance benefits begin after the elimination period. The elimination period occurs 13 weeks after the employee has an accident. If the company covers the employee’s sick leave, the benefits start after that. The benefits begin after whichever event happens later.

The insurer pays monthly. The insurance company makes the first payment after the elimination period ends.

Here is a simple guide to the disability insurance claim process in Canada. Most insurance companies follow these steps.

1. Claim Submission to the Insurance Company

When you submit your claim, make sure you attach the following completed forms: 

  • Employee Statement (TBS/SCT 330-302) 
  • Employer’s Statement (TBS/SCT 330-303) 
  • Employee’s Medical (TBS/SCT 330-304)

The Insurance Company will acknowledge receiving your claim submission within five business days. Then, it will start evaluating the claim.

Providing Incomplete Information

The Insurance Company will notify you by letter if your claim lacks information. It also sends a copy of the communication to your department.

2. Claim Evaluation Process

The Insurance Company will check your claim ten business days after you submit the forms. They will decide if you are eligible for insurance benefits. 

  • If the company approves your claim, go to Step 3. 
  • If the company denies your claim, go to Step 2A.

2A. Claim Rejection

When the insurance company denies your claim, they will send you a written notice. The notice will have specific details. It will explain what you need to do if you want to appeal the decision.

2B. Appeal Process

1st Appeal: The Insurance Company will review any new information you provide. If the decision remains the same, it will issue a letter. The letter will explain the decision. It will specify the information needed for a second appeal.

2nd Appeal: The Insurance Company will conduct another review after getting new information. If the decision stays the same, it will send a letter with its final decision. In case they choose to keep the claim closed, this is the end of the insurer’s internal appeal process.

  • If the company approves your claim, move on to Step 3.
  • If the company denies the claim, you can request an independent review by DI BOM.

DI BOM – Disability Insurance Plan Board of Management

Once you have gone through all the appeals for your disability insurance, you can choose to get an independent review. The Disability Insurance Board of Management (DI BOM) does this review. The board has both management and government representatives. It gives reports to the National Joint Council.

The DI BOM reviews each case. They propose a course of action to the insurer or the employee. Their goal is to find a resolution. These recommendations are not binding. These experienced boards have resolved many cases. They work to please all parties.

3. Claim Approval

During the disability insurance claims process, the insurer will send you a letter once they approve your claim. The letter will explain all the calculations. It will also provide the start date of your benefits. It will state the exact amount you will receive.

Payment Process Post Claim Approval

Once the insurer approves your claim, it makes payments according to a schedule.

After the elimination period, benefits become payable. The elimination period concludes after 13 weeks of total disability. It also concludes when your paid sick leave ends. It depends on which happens later.

  • Companies generally issue monthly payments.
  • Most insurance companies make the first payment at the end of the month. (The month in which your elimination period concludes).

4. Vocational Rehabilitation

In this stage, vocational rehabilitation focuses on preparing you for a secure return. It considers your unique abilities and limitations.

Your personalized return-to-work plan may include a gradual reintroduction to work tasks. It may also include a transition to modified or part-time responsibilities. This can help you adjust to work with ease. If your return requires specialized insights, a Health Management Consultant (HMC) could help. They coordinate for your reentry into the workplace.

The Consultant (HMC) collaborates with you, your employer, and your healthcare providers. Together, you craft a personalized return-to-work plan. They team up with the Abilities Case Manager (ACM). Integrating this plan early into your treatment program increases the likelihood of success. 

The HMC may use a variety of career and vocational rehabilitation services. They will help you make a complete and effective comeback.

The Bottom Line

Navigating the disability insurance claims process may feel overwhelming. Remember that you are not alone. By following the steps above, you can feel confident in the claims process. Whether it’s submitting your initial forms, managing appeals, or planning your return to the workplace, stay informed. Don’t hesitate to reach out to your insurance broker who sold you this policy for additional help with claims as well.