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long term disability lawyer keeping record of disability claim

Many employers in Nova Scotia have long-term disability coverage, not through a typical insurance company, but through a “self-insured” plan governed by a health and welfare legal trust fund titled the NSAHO Long-Term Disability (LTD) Plan. The self-insured nature of the Plan means the employers assume the financial risk of providing health care benefits to employees out of pocket instead of paying a fixed premium to an insurance provider, which is known as a fully-insured plan. Benefits are paid not from the Health Association Nova Scotia or its officers or directors, but from the Trust.

Understanding NSHA and the NSAHO LTD Plan

Health Association Nova Scotia (NSHA), formally Nova Scotia Association of Health Organizations (NSAHO), is a not-for-profit, non-government, membership-based organization with almost 60 years of experience in delivering shared services. One of their core service offerings is a range of comprehensive group benefits solutions. Serving over 40,000 active employees and 8,000 retirees, they are the largest, longest-standing provider of group benefits administration services in Nova Scotia’s health system.

A Board of Trustees reporting to the NSHA Board of Directors is comprised of equal union and employer representation from both acute and non-acute care sectors. Acute care covers sudden injuries that are short-term and urgent in nature, usually associated with a traumatic event. Non-acute care covers maintenance and long-term care for non-urgent matters and requires professionals to see patients multiple times.

Where an insurance company comes into play with the NSAHO LTD Plan is in the role of the Claims Adjudicator. In the case of the NSAHO LTD Plan, the Plan is currently administered by an insurance company, Manulife, through an Administrative Services Only Agreement (ASOA). As the Claims Adjudicator, their role is to receive, assess, and make decisions about long term disability claims under the Plan.

Can I Sue NSAHO for LTD Benefits?

If you take legal action against the NSAHO Disability Insurance Plan, you must start legal proceedings within one year of your LTD benefits being denied or terminated.

If you have been denied long-term disability insurance, you are likely wondering who exactly you’d be suing, especially under a self-insured plan. In most LTD denial lawsuits, you are suing the insurance company because they are the ones who decided to refuse payment of your benefits.

However, this is not always the case. Sometimes a lawsuit is made against your employer, the Board of Trustees who oversee the Plan, or, in rare cases, the broker who sold you the policy.  Occasionally, you will commence a claim against the ASOA if they act in bad faith in a manner that was not part of their mandate.

Please note that there is conflicting case law across the country about whether an ASOA can be sued for bad faith, with the majority of courts saying that they can.

Do I have to go to court?

To our knowledge, the Trustees have never proceeded to trial on an LTD claim made under the Plan. That does not mean that you are certain to succeed, it just means that the Trustees and the applicant eventually find a way to compromise.  You do not always have to go to court when pursuing an LTD lawsuit. Lawsuits, especially against an insurance company, often end up being settled through negotiations between your LTD lawyer and the insurance company representatives outside of court. If settlement negotiations and mediation fail, then you will end up in court with a judge or jury deciding if your benefits will be reinstated or not.

But more often than not, you will need to commence an action against the Trustees to resolve your LTD claim, as the vast majority of appeals are not successful.

Who you will be suing for being denied long-term disability depends on the specifics of your case. To understand who you will likely be up against, you can contact our long-term disability lawyers for a free consultation.

Proving Eligibility for Disability Benefits

To be eligible for disability benefits, you must first be eligible to be covered by the insurance plan.

You are eligible for LTD coverage if you are:

  • A permanent employee hired to work at least 28 hours every two weeks on a permanent basis, or
  • A permanent, part-time employee who is not regularly scheduled to work at least 28 hours every two weeks but who, over the year, works on average 28 hours or more every two weeks.

Any employee covered by NSAHO Disability Insurance can make a claim. The first step to obtaining benefits is by filing a Proof of Claim form. This form shows that you are still and were totally disabled while covered under the Plan. This form must also clearly show that you have remained totally disabled throughout the 150 day elimination period.

It is the employee’s responsibility for providing the Claims Adjudicator (Manulife) with the Proof of Claim to prove your entitlement to benefits. The Proof of Claim must contain sufficient evidence to establish your initial and ongoing eligibility for benefits and that you have an ongoing disability preventing you from working in your occupation.

To be considered eligible, past the requirements of being totally disabled, you must also continue to have permanent employment status with the same employer. If your hours fall below the minimum hours required to be considered eligible, you will still be eligible as long as your employment status is maintained.

How Much of a Monthly Benefit Could I Receive Under the NSAHO LTD Plan?

You will be eligible to receive a monthly benefit equal to 70% of your monthly salary at the time of your disability. Your monthly LTD benefit is considered as taxable income.

Under the Plan, several other forms of income can be used to offset the payment, such as:

  • Canada Pension Plan, except dependent benefits.
  • Quebec Pension plan or US Social Security disability benefits
  • Any employer group or professional association disability plan
  • And many other forms of income

What is the Process of Receiving LTD Benefits from NSAHO?

Time Limits

Your LTD application forms should be submitted to your Benefits Administrator as soon as possible. This could help speed up the assessment of your claim and determine if participation in a rehabilitation program could help you. Before you can receive LTD benefits from NSHA, there is a 150-day elimination (or waiting) period. You must submit your application for LTD within seven months after the end of the elimination period. If your application is submitted beyond the seven-month time frame, your benefits will be payable no earlier than the date the application is received. This means you will not receive any retroactive payments you would otherwise be entitled to. No benefits will be paid to you if your application is submitted more than 19 months after the elimination period’s expiry.

The following information is taken from the NSHA website and outlines the process of what you’ll need to receive LTD benefits from your NSAHO Disability Insurance Plan:

Claim Forms

The following forms must be fully completed and submitted to your Benefits Administrator to make an LTD claim:

  • Employee/Member Statement
  • Authorization and Consent Form
  • Canada/Quebec Pension Employee Agreement
  • Direct Deposit Application (including sample cheque marked VOID)
  • Workers’ Compensation Benefits Employee Agreement
  • Attending Physician’s Statement

Click here to go to Forms and Documents.

Required Additional Information

As well as the required forms, you’ll need to send in the following with your application for Long Term Disability:

  • An up-to-date Job Description (ask your supervisor for a copy).
  • Copies of correspondence from the Workers’ Compensation Board (WCB), indicating the status of a claim, if WCB is involved.
  • Copies of correspondence from Canada Pension Plan (CPP), indicating the status of a claim, if CPP is involved.
  • A copy of your Birth Certificate or valid Driver’s License.

Optional Additional Information

If you have any of the following information available to you, we recommend that you send it along with your application:

  • Current copies of all medical reports and information about the illness or injury that led to your claim for LTD, such as:
    • Specialists’ consult reports.
    • Results of investigative diagnostic procedures (such as X-rays, Blood work, Biopsies, MRIs, CT Scans, Bone Scans, EKG reports, etc.).
    • Hospital Admission and Discharge summaries.
    • Operating Room reports.
    • Neuropsychological testing results.
    • Psychological Initial Assessment report and Progress reports.
    • Occupational Therapists Initial Assessment reports and Progress reports.
    • Physiotherapy Initial Assessment reports and Progress reports.
    • Functional Capacity Evaluation results.
  • Copies of clinical notes since the date your health became affected.
  • Current copies of all medical reports and information from the Occupational Health Department about the illness or injury that led to your LTD application. This includes information about any ongoing and/or attempted modified work or return to work programs.

It is vital that you provide the most current medical information available. Once you’ve filled in the forms and gathered the above information, give them to your Benefits Administrator.

What Happens to my Nova Scotia Health Employees’ Pension Plan (NSHEPP) While I’m on LTD?

If you are disabled and in receipt of LTD benefits from an employer-sponsored LTD plan:

  • You will remain a member of the pension plan, but contributions will be waived, and
  • You will continue to earn pensionable service during your period of disability.

Do I Need a Lawyer to Receive LTD Benefits from NSAHO?

Making a claim with NSAHO for disability benefits is a cumbersome process with a pile of paperwork. Submitting all required forms and information, providing as much valuable additional optional information as possible, is essential to getting your application processed and approved.

Working with the experienced and organized LTD lawyers from Valent Legal can help ensure your application process is not delayed by making sure everything is in order and the right information you need to get approved is included. Our lawyers also understand the information that your Claim Adjudicator might twist to use to deny your claim and advise you to leave specific details out of your claim to increase your chances of coverage from NSAHO disability insurance.

If you’ve been denied long-term disability or need help with your NSAHO disability insurance application, contact our LTD lawyers for a free consultation today.

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