Guide To Long COVID & Disability Benefits

COVID-19 causes long lasting symptoms in a significant percentage of those infected with the virus. Various terms for this persistent illness have been adopted, including “post-COVID-19 syndrome”, “Long COVID-19”, and “Long Covid”. Some suffers use the term “long hauler”.  The most common symptoms are fatigue, muscle weakness, impaired mobility, pain, anxiety, and depression, according to a recent study published in the prestigious medical journal, The Lancet.

COVID-19 long haul symptoms have attracted media attention as well. Recent headlines include:

• Researchers Are Closing In On Long COVID – The Economist
• First Public Survey On Canada’s COVID-19 Long Haulers Reveals Enduring “Brain Fog”, Fatigue – The Toronto Star
• There’s a shortage of services to help the growing number of long-haul COVID-19 sufferers – The Globe and Mail

Acknowledgment by scientists, doctors, and the media is a good starting point.  But for some COVID-19 long haulers, disabling symptoms make work impossible, adding financial stress to already disabling medical issues. Fortunately, many people who are unable to work have short and long term disability benefits available, either through their employer’s group plan or an individual policy.  This blog post provides an overview of STD and LTD benefits in the context of COVID-19 long haul symptoms. 

For individuals who do not have short or long term disability coverage, other income replacement options may include WISIB (if the virus was contracted at the workplace), Employment Insurance, Ontario Disability Support Program (or similar programs in other provinces), and Canada Pension Plan Disability benefits.  These are, however, beyond the scope of this blog post.

Short Term Disability Benefits

Short term disability benefits usually provides 50 to 100% salary for 8 to 52 weeks, depending on the employer and the wording of the policy.  Often the employer is responsible for payment of STD benefits, but arranges for an insurance company to administer the plan; that is, an outside insurer reviews the medical records and makes decisions regarding eligibility.

When an STD claim is approved, the insurer or other administrator will continue to monitor the claim to ensure ongoing eligibility.  You can expect the insurer to be in regular contact regarding your diagnosis, treatment, activity level, and to obtain other related information.  You are responsible for either providing supporting medical evidence, or signing authorizations so the disability insurer can obtain it directly.

If symptoms of long haul COVID-19 prevent a return to work for longer than the duration of short term disability benefits, you may then become eligible for long term disability benefits.  

Long Term Disability Benefits

LTD usually starts when STD ends, or after some other defined waiting period.  Like short term disability, long term disability will pay a percentage of your income, but potentially for a much longer period.  Most LTD policies provide benefits in the range of 50 to 70% of your income, until the earliest of your ability to return to work, age 65, or death.

Long term disability benefits are taxable if your employer paid part or all of the premiums.  If you paid 100% of the premiums, any benefits received are not taxable.

 

Applying For LTD

If the short and long term disability insurers are the same, there is usually no requirement to make a separate application for LTD benefits.  Instead, the insurer will review the existing information and make a decision. 

If you do have to make a separate application for long term disability benefits, there are usually three forms to complete: one by you, one by your employer, and one by your doctor.  It is helpful if your doctor also provides recent clinical notes and records, together with a brief report outlining your restrictions and limitations.

Generally, the more information you can provide the insurance company the more likely your STD and LTD claims will be approved.  It is also important to focus or your level of function, rather than the diagnosis alone.  For more information about applying for disability benefits, consider this blog post: Applying For Long Term Disability Benefits: Top 10 Tips

 

Qualifying For LTD

In order to qualify for long term disability benefits, the insurance policy requires “total disability”, or for you to be “totally disabled”.  This is not as difficult as it sounds.  There are actually two different tests of disability in most policies.  For the first two years (although it could be shorter or longer, depending on the policy) you must be disabled from your “own occupation”; that is, if you cannot complete the important tasks of the job you had before your disability, you should qualify for benefits.

If you cannot work for more than two years (again, the timing could be different, depending on the policy), the test of disability changes from disabled from your “own occupation” to being disabled from “any occupation”.  This does not mean you have to be disabled from any job in the literal sense; rather, you must be disabled from any occupation for which you have the required training, education, and experience.  A highly educated professional is not required to work in manual labour and a labourer is not required to work in an office in order to meet the “any occupation” test of disability.  

 

What To Expect In The Claim Process

An insurance adjuster will be assigned to your claim.  Their job is to gather information about your disability to determine whether you are able to return to work.  The adjuster will consider multiple factors when making this decision, including:

• Is there a diagnosis?
• Are there other medical issues?
• What are the symptoms?
• What is the level of function?
• Do the medical records support the reported symptoms and level of function?
• Are social media and other online searches consistent with the reported limitations?
• What is the treatment plan?
• Is the treatment appropriate?

Long haul symptoms due to COVID-19 bring some challenges to the claims process.  Some doctors are reluctant to make the diagnosis, misdiagnosis is common, and sometimes there is little supporting documentation, other than self reported symptoms that can be difficult to objectively verify.  This does not mean persistent COVID-19 symptoms are any less disabling than other injuries or illnesses, but it does make it harder to verify when claiming benefits from an insurance company.

When a medical condition and the level of impairment cannot be objectively determined, disability insurers will investigate non-medical factors that may contribute to being off work. For example, childcare obligations, the availability of work, or a move to another city may be a concern for the insurer.  Again, none of these factors mean you are not disabled; but, the insurer may wonder if there is another reason, a non-medical reason, that may be contributing to the workplace absence.

This reluctance to accept self reported restrictions and limitations as sufficient to approve claims is not unique to COVID-19 long haul symptoms. Similar stigma exists in society for depression, anxiety, chronic pain, fibromyalgia, and chronic fatigue syndrome.  

 

Medical Assessments

STD and LTD adjusters sometimes seek guidance from internal medical consultants. These doctors are paid by the insurance company to review the available medical records and comment on whether the records support an inability to work.  Less frequently, insurers will arrange for an in person independent medical examination with a doctor of their choosing.  There is generally a clause in the policy that requires you to attend the medical examination if the insurer asks you to. If you don’t, it could result in a refusal to pay benefits.

 

Rehabilitation Assistance

The insurer may also arrange for help with getting back to work. Most insurance companies have access to a network of vocational rehabilitation consultants. The idea is to help facilitate a successful transition back to employment through a combination of treatment, retraining, “work hardening”, and other interventions.  There is usually an obligation to participate in vocational rehabilitation if offered, but you do have the right to seek medical clearance from your primary care provider first. You may also want to consider legal advice if you or your doctor has concerns about the vocational rehabilitation being proposed.

 

What To Do If Your Claim Is Denied

The majority of short and long term disability claims are approved on initial application.  Anecdotal evidence suggests that most long haul COVID-19 claims are similarly being approved, but at some point the insurer will not agree to continue paying benefits.

If your claim is denied, there are generally three options: attempt a return to work, appeal the decision, or commence legal action.

If you attempt a return to work, you should be aware that there is a recurrence provision in the policy.  This means that if you have to stop working within a specified timeframe, often six months, then you do not have to start the process all over again, but rather continue with the original claim.

If you cannot return to work despite a denial, you can appeal on your own or with the help of a lawyer.  If you are unionized, the union might assist with the appeal, although they often do not have sufficient resources to do so effectively. Appeals are unfortunately rarely successful.  STD and LTD appeals are not decided by a neutral decision maker; rather, they are decided by the same company that denied the claim in the first place.   For this reason, most long term disability lawyers do not recommend appeals.  If you do wish to appeal, you may find this blog post helpful: How To Write A Long Term Disability Appeal Letter: Top 10 Tips

If you decide against an appeal, or of the appeal is denied, you can take legal action.  This requires filing documents with the court disputing the denial.  Most LTD lawyers do not charge any fees unless the lawsuit is successful as set out in a contingency fee retainer agreement. The lawyer receives a percentage of the total recovery, if successful. 

Insurance companies do not want denied disability claims going to trial for a variety of reasons.  When a lawsuit is commenced, there is a very high chance of settlement long before the case gets anywhere near a courtroom.   Settlements consist of either payment of the past benefits owed and reinstatement of benefits, or a single lump sum payment for past and future benefits.   If a lump sum, the size of the settlement will depend on the benefit amount, your age, the strength of the medical evidence, and other factors.

Conclusion

Short and long term disability benefits are intended to provide a source of income for people who are unable to work due to illness or injury.  This coverage extends to COVID-19 long haul symptoms, so long as the medical and other evidence supports disability.

It appears that so far most insurance companies are approving COVID-19 related claims. If your short or long term disability claim is denied, consult a long term disability lawyer for free advice.  

 

About The Author Michael Jordan is a long term disability lawyer with more than 17 years experience litigating all types of insurance claims.  He is a founding partner of the Bay Street firm Jordan Honickman Barristers.   Michael represents clients across all of Ontario, with satellite offices in Ottawa and London. Email: mjordan@jhbarristers.com Direct Cell: 416-460-6823