Documenting a Disability Claim (Benefit Tips ® - © 1999)

The purpose of disability insurance is to replace employment income while an employee is unable to work, as the direct result of their disability. The financial instrument used to achieve that purpose is an insurance contract.

While many disability insurance claims are resolved to everyone’s satisfaction, some are contested. As with any contract, the final step in resolution is litigation.

The challenge of the claimant is to make it as easy as possible for the insurer to approve the claim, while collecting enough evidence to prevail in the event of litigation. The claimant needs copies of the following documents in order to protect their interests:

• insurance contract
• enrolment form
• job description
• claim form
• attending physician statements
• notes or recordings of interviews
• daily medical journal
• correspondence
• claim payment cheque stubs or statements

The most helpful step, in building a comprehensive claim file, is to obtain a supply of blank “Attending Physician Statements” and have each physician complete one at the end of each visit. The claimant sure to discuss the findings with the physician and request a copy before it is submitted to the insurer. This eliminates delays and can improve everyone’s understanding of the recovery process.

It is imperative that the claimant has detailed and an accurate record of all meetings and telephone interviews with investigators and recovery personnel. Be sure to obtain advice from your lawyer and notify the other party before recording these interviews.

The claimant should keep a daily journal of how they feel, change in medications, therapy received, recovery achievements, setbacks, appointments, work schedules, etc.

Keep in mind that the claim adjudicator’s function is to approve legitimate claims, control costs and deny illegitimate claims. Expect a healthy dose of scepticism and don’t resist an independent medical exam, a functional-capacity assessment, rehabilitation or retraining. The claimant’s responsibility is to mitigate the loss and move toward self-reliance as quickly as possible.

Health Claim Decisions (Benefit Tips ® - © 2009)

You can maximize the value of your benefit plan by making careful purchase decisions and shifting claims to preserve your benefit coverage.

Ensure You Receive Value

Medication

• Dispensing fee: The professional fee charged by pharmacies varies and should reflect the level of service provided.
• Ingredient cost: The lowest available ingredient cost should be used in the pricing calculation.
• Markup: The markup on ingredient cost varies by pharmacy

Dental

• Frequency: How often you see your dentist should depend on your biology and oral hygiene practices. Some people need to go every 3 months while annually is fine for others.
• Markup: The rates charged by dentists differ.
• Specialists: The quality provided by a specialist often exceeds the incremental price difference.

Coordinate with Other Plans

Submit claims to other plan before using your health spending account. Page 4 of the Canadian Life and Health Insurance Association Inc. Guideline G4 - Coordination of Benefits specifies that claims should be submitted to a health spending account only after claims have been made through all other group insurance plans.

Become aware of coverage through your provincial health plans such as the Ontario's Trillium Drug Plan and Ontario's Assistive Devices Program.