Eligibility for Long Term Disability Income benefits directive

Overview

This directive describes how eligibility for benefits is determined, when employees are eligible for benefits, return to work and conditions for eligibility under the Long Term Disability Income (LTDI) Continuance Plan.

Elimination period

When bodily injury or illness causes an employee to be away from work for at least 80 consecutive normal work days or the equivalent number of hours of work, the period starting from the day the employee stops or partially stops work is called the elimination period.

If an employee returns to work during the elimination period and then takes general illness leave for the same or a related illness within 10 consecutive work days of returning to work, the time the employee was at work is considered part of the elimination period.

If an employee returns to work after an absence caused by a disability, is no longer receiving disability benefits, and is disabled as a result of the same or a related condition within six months after the date long term disability benefits payable terminate, the disability is considered continued and another elimination period is not served.

Review of injury or illness

A disability is a medical condition that causes an employee to be unable to perform any combination of duties that regularly took at least 60% of the employee's time at work to complete before the injury or illness, or that makes the employee unable to be gainfully employed.

Gainful employment is employment that the employee is medically fit to perform, for which the employee has at least the minimum qualifications, and that provides a salary of at least 60% of the employee's pre-disability salary.

For information on reviews of the adjudicator's decisions, see directive LTDI Adjudication Review.

Determination of eligibility

When the adjudicator determines that an employee's bodily injury or illness results in a disability, and the disability continues during the entire elimination period, the employee is eligible for benefits beginning immediately after the elimination period.

An employee will not be eligible for benefits payable after the elimination period for:

• a disability suffered as a result of participation in commission of a crime
• a disability suffered as a result of an act of war
• an intentionally self-inflicted injury or illness
• any period during which the employee is not under the continuous care of a physician or following the treatment a physician prescribes
• a period of incarceration in a prison or similar institution

Pre-existing condition

Benefits will not be paid for any medically documented injury or illness for which an employee received medical services, supplies, or any medication prescribed by a physician during the 90 days immediately preceding the effective date of permanent or temporary employment. This does not apply to an employee who has been employed in a permanent or temporary position for two consecutive years and is not absent from work because of a pre-coverage injury or illness on the date the two years are completed.

If the employee has been employed in a permanent or temporary position for two consecutive years but is absent from work because of a pre-coverage injury or illness at the two-year point, the employee is eligible for coverage under the plan on the date the employee returns to work.

Interim payment

If the adjudicator does not decide on an employee's eligibility for benefits before the end of the elimination period, the deputy head may order that the employee continue to be paid at the rate of 70% of the employee's normal salary for up to 2 months or until the date the decision is received, whichever comes first. The employee is not entitled to receive this interim payment and benefits for the same period. For more information, see directive Administration of LTDI benefits.

Return to work

If the adjudicator determines that an employee is capable of returning to their own job within the 24 month period after receiving benefits:

• the employee will be returned to their own job, or
• the employee will be returned to a similar job.

An employee must be returned to the job within 30 days from the adjudicator's decision.

Gainful Employment – If the adjudicator determines that an employee is disabled from performing regular duties but is fit for gainful employment, the employee is eligible for:

• benefits for up to three months from the date of being assessed by the adjudicator as fit, or the date of gainful employment, whichever comes first
• income maintenance for up to 36 months from the date of being found fit for gainful employment or until the employee's 65th birthday, whichever comes first

If an employee is gainfully employed within three months from the date of being found fit for gainful employment and has not received a severance payment, the employee will receive payments in the amount equal to the difference between the pre-disability salary and the employee's income from the gainful employment.

If an employee is not employed within three months from the date of being found fit for gainful employment, no further benefits are payable and the employee will be released from employment with eligibility to receive severance pay equivalent to the greater of:

• 2 months' pay
• 1.5 weeks' pay for each full year of continuous employment to a maximum of 25 weeks' pay as per the Public Service Employment Regulation
• an amount equal to an amount payable under a separation payment for restructuring calculation, if in force

Outplacement services

An employee, upon being found no longer disabled from regular duties after 24 months of receiving benefits or being found fit for gainful employment and who has not received outplacement services in conjunction with a rehabilitation program, will be eligible to receive outplacement services.

Conditions for eligibility

If substance abuse, including alcoholism and drug addiction, contributes to an employee's disability, the employee's treatment program must include participation in a recognized substance withdrawal program (see directive LTDI Rehabilitation Program).

Depending on the nature and severity of an employee's condition, the adjudicator may require an employee to be under a specialist's care.

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