Long-Term Disability Benefits

What am I insured for?

To qualify for benefits, your claim must provide satisfactory proof that, while insured under this plan, you became totally disabled (as that term is defined in the Policy) and therefore unable to work.

The purpose of this benefit is to insure for wage loss should you become totally disabled as a result of a medically diagnosed sickness or injury and unable to work. Therefore, if there is no lost income, benefits are not payable.

The monthly benefit for which you are covered is based on your monthly salary and the benefit formula indicated in the schedule of benefits. The amount payable is the monthly benefit amount less the reductions listed under the benefit reduction section in this booklet.

Excess Long-Term Disability Insurance

If your salary qualifies you for an amount of insurance in excess of the non-evidence maximum (NEM) shown in the schedule of benefits, your long term disability insurance may be increased to an amount not exceeding the health evidence maximum (HEM) shown in the schedule of benefits, provided evidence of good health is approved in writing by Co‑operators Life.

What conditions do I need to satisfy before and during the payment of benefits?

Independent Medical Assessment

It is a condition prior to the initial payment of benefits and any continuing payment of benefits that you will, if we require, undergo medical assessment(s), by one or more medical practitioners chosen by us.

Continuous Obligation

Your obligation to undergo medical assessment exists during any period for which you claim benefits.

Participation in Rehabilitation Program

It is a condition prior to and while you are receiving benefits, that you will, where requested by Co-operators Life, participate in a rehabilitation program considered appropriate by Co-operators Life, including but not limited to an approved rehabilitation program offered through worker’s compensation legislation or similar statute.

Pre-existing Condition Limitation

Pre-existing condition means a sickness or injury for which you sought medical investigation, diagnosis, diagnostic measures, treatment, care medication, or medical advice, or for which there were symptoms that would have caused a person acting reasonably to seek medical investigation, diagnosis, diagnostic measures, care, treatment, medication or medical advice within the 90 day period immediately prior to becoming insured under the long term disability benefit.

No monthly benefits will be payable for any period of total disability which results directly or indirectly from a pre-existing condition, unless:

you have not required treatment, medication, or medical advice for the condition for a continuous period of at least 90 days immediately following the effective date of your long-term disability coverage, or
you have been insured continuously under this long-term disability plan for at least 12 months (from the date your insurance became effective or reinstated) and you have not been absent from work during the 12-month period as a result of the pre-existing condition. Time away from work up to 10 cumulative working days during the 12-month period will be interpreted as not being absent from work.

Payment of Monthly Benefits

During the Own Occupation Period

Where Co-operators Life receives satisfactory proof that you:

are and have been totally disabled since the disability date,
have suffered a loss of income,
are receiving and following reasonable and customary treatment prescribed and rendered by a general physician or specialist where considered appropriate by Co-operators Life, and
have satisfied all of the other relevant conditions contained in the policy,

Co-operators Life will, subject to the provisions of the Policy, pay to you a monthly benefit effective the day following the completion of the elimination period and payable for the maximum duration of your own occupation period as indicated in the schedule of benefits.

After the Own Occupation Period

Not applicable to Long-Term Disability plans that only have a 24-month benefit duration.

Where we receive satisfactory proof that you:

are and have been totally disabled since the disability date,
have suffered a loss of income,
are receiving and following reasonable and customary treatment prescribed and rendered by a physician or where we consider appropriate, a specialist, and
have satisfied all of the other relevant conditions contained in the policy,

We will, subject to the provisions of the policy, continue to pay you a monthly benefit.

When will benefits begin?

Your benefits will begin the day following the end of the elimination period indicated in the schedule of benefits or the day following the end of the period during which you are receiving short-term disability benefits under this plan or salary continuation benefits from any other source, whichever is later.

The elimination period refers to the time frame of total disability that must be satisfied before you qualify to make a claim for benefits. Benefits are not payable and premiums are not waived during this period.

What if I work during the Elimination Period? (if your elimination period is less than 180 days)

If you return to active work for 7 consecutive days or less, your elimination period will be considered to be uninterrupted, but the days you worked will be added to the end of your elimination period. If you return to active work for more than 7 days, your elimination period will be reinstated and you will be required to satisfy the complete elimination period before benefits are eligible to be paid.

What if I work during the Elimination Period? (if your elimination period is 180 days or more)

If you return to work for a period of 14 consecutive days or less, your elimination period will be considered to be uninterrupted, but the days you worked will be added to the end of your elimination period. If you return to work for more than 14 days, your elimination period will be reinstated and you will be required to satisfy the complete elimination period before benefits are eligible to be paid.

Recurrence of Total Disability

Your total disability is considered a recurrence if it arises from the same or related sickness or injury within 6 months from the date your benefits ended.

Benefits are Pro-Rated for Partial Months

Monthly benefits payable for periods less than a full month will be pro-rated based on the actual number of days in the applicable month.

Are my benefits taxable?

Your benefit payments are taxable. According to information provided by LiUNA 493and our current records, the tax status is stated in the schedule of benefits.

Rehabilitation Program

A Rehabilitation Program is provided at our discretion and may include rehabilitation assessment, and/or rehabilitative employment, and/or rehabilitative treatment, and/or rehabilitation services recommended and approved by us.

Approval of Rehabilitation Program

Co-operators Life will have sole discretion in determining whether or not a rehabilitation program is appropriate and/or provided for any plan member. Once the rehabilitation program is approved, Co-operators Life may issue, if eligible, monthly benefits to a totally disabled plan member who continues to participate and co-operate in an approved rehabilitation program.

The rehabilitation program duration will be determined by us, however, it will not extend beyond the end of the own occupation period indicated in the schedule of benefits or 24 months from the date of your disability, whichever is later, unless an extension of the duration is recommended and approved in writing by Co-operators Life.

Calculation of Monthly Benefits during a Rehabilitation Employment Period

If you participate in rehabilitative employment approved by us, your benefit will be reduced by 50% of your rehabilitative earnings. The monthly benefit payable during rehabilitative employment will be calculated after 4 weeks of earnings have been reported to us, payable monthly, and adjusted periodically.

Your benefit may be further reduced by any amount necessary to reduce the total income you receive from all sources to 100% of the monthly salary for which you were insured immediately prior to the start of your disability.

Your monthly benefits will cease on the earliest of:

the date you refuse to participate or co-operate in any rehabilitation program recommended or approved by us including but not limited to any rehabilitation program offered through any worker’s compensation legislation or similar statute, auto plan benefits or Canada Pension Plan, or
the withdrawal of our approval of your rehabilitation program.

Benefit Reductions

What reductions occur when determining my Monthly Indemnity Benefit payment?

All Source Maximum – Ceiling on the Monthly Benefit

For non-taxable long-term disability plans, the amount of your non-taxable benefit will be limited to the lesser of the amount of insurance for which you are covered or 85% of your pre-disability net monthly salary.

Your net salary is your gross salary minus involuntary deductions for federal and provincial income tax, employment insurance premiums (EI), and Canada/Quebec Pension Plan contributions.

For taxable long-term disability plans, the amount of your taxable benefit will be limited to the lesser of the amount of insurance for which you are covered or 85% of your pre‑disability gross monthly salary.

All Source Compensation – Direct Reductions

Your monthly benefit will be reduced directly by one or more of the following, which you are receiving or entitled to receive at the time your benefits commence and/or while benefits, are paid:

any government plan benefits,
any auto plan benefits,
any Canada or Quebec Pension Plan retirement benefits you apply for were approved for and received after your disability date,
any compensation for loss of income you receive from a third party or are entitled to receive after your disability date.

All Source Compensation – Indirect Reductions

Your benefit will be further reduced if the total of the following all source compensation and your monthly benefit exceeds 85% of your pre-disability gross monthly salary for taxable plans, and your net monthly salary for non-taxable plans. If it does, your monthly benefit will be reduced by the amount in excess of 85% by:

any amount you are entitled to under a salary replacement benefit as a result of your disability, and
any compensation you receive or are eligible to receive while employed or while performing work of any sort, excluding rehabilitative earnings which are considered under the rehabilitation program, and
any payment made to you by your plan sponsor as a result of termination including without limitation any payment made by way of settlement or judgment, and
any disability benefits you are eligible to receive under any other group or association plan as a result of being a plan member of a group or a member of an association.

Failure to Apply or Accept Other Benefits

Except for retirement benefits, any benefit is considered paid when you are entitled to it, whether or not it has been awarded or received. If it has not been awarded or received, Co-operators Life will have the right to estimate the income according to the terms of any plans or legislation involved. Retirement benefits are considered payable when they are actually received.

Where you do not qualify for part or all of the all source compensation because of failure to apply in a timely and satisfactory manner (or appeal where so advised by Co-operators Life),
we reserve the right to reduce your monthly benefit by the amount of all source compensation, which you would have been eligible for or received had a proper application or appeal been made.

Lump Sum Conversion to Monthly Benefit

Where you receive or have the option of receiving part or all of the all source compensation as a lump sum payment, we will, acting reasonably, pro-rate the lump sum payment and reduce your monthly benefit as if the lump sum had been paid on a monthly basis.

Repayment of Benefits

Where you receive all source compensation that includes compensation for a period for which monthly benefits have been paid, we will convert the payment to a monthly payment and recalculate your monthly benefit that should have been paid. You are responsible to repay Co-operators Life any overpayment of long-term disability benefits.

Total Disability Waiver of Premium

We will waive your long-term disability premiums while you are receiving benefits.

When do my Long Term Disability Benefits terminate?

No monthly benefits will be paid beyond:

the date you cease to be totally disabled, or
the benefit duration indicated in the schedule of benefits or your 65^th birthday, whichever first occurs, or
the date you begin working in any occupation, except as provided for under the rehabilitation program, or
the date you refuse to participate or co-operate in any rehabilitation program recommended or approved by Co-operators Life including but not limited to any rehabilitation program offered through workers compensation legislation or similar statute, or
the date you refuse to participate or co-operate in a reasonable and customary treatment program approved by Co-operators Life, or
the date of your death, or
the date you retire or were scheduled to retire, or
the date you withdraw or receive LiUNA LOCAL 493 pension funds.

A reasonable and customary treatment program is systematic treatment that is:

generally accepted and recognized by the Canadian medical profession as effective, appropriate, and essential in the treatment of the medically diagnosed condition, and
of a nature, intensity, frequency, and duration essential to the diagnosis or management of the medically diagnosed condition involved, and
prescribed and rendered by a physician or where considered appropriate by Co-operators Life for the nature of the medically diagnosed condition, the treatment must be prescribed and rendered by a specialist.

No monthly benefits will be payable during any period while you are:

serving a sentence for a criminal or provincial offense whether you are imprisoned in a halfway house, a correctional facility, or any other form of detention, or
absent from Canada longer than 3 months due to any reason, unless we agree in writing in advance to continue to pay your benefits during this period, or
receiving short term disability benefits under this plan or salary continuation benefits from any other source, or
on maternity/parental or compassionate (family) leave and receiving or eligible to receive employment insurance (EI) benefits or maternity or parental benefits from any other source, or
becomes disabled during a work stoppage, including but not limited to strike, lay-off, lock-out, suspension, or leave of absence, except as provided below:

Maternity/Parental/Compassionate Leave or Temporary Leave or Lay-off

If you become totally disabled while on maternity/parental/compassionate leave, a temporary leave or lay-off, provided premiums have been paid the elimination period will commence on your disability date, and benefits will begin on the later of the end of the elimination period or the date you were scheduled to return to active work.

A scheduled leave is deemed to commence on the date agreed upon by you and your plan sponsor and end on the date you were scheduled to return to active work. If a child is born prior to the date upon which your maternity leave is scheduled to commence, the leave is deemed to commence on the date of birth.

If your plan sponsor is required to provide benefits during the health-related portion of your maternity leave as a result of law or legislation, the elimination period will begin on the date your child is born and benefits will begin after you have satisfied the elimination period.

What limitations are there on LTD benefits?

No monthly benefits will be payable for any period of disability resulting directly or indirectly from any of the following:

insurrection, war (whether declared or not), voluntary participation in a civil riot or commotion, or
committing or provoking an assault, committing or attempting to commit a criminal offense, or
a situation where the disability results from injuries sustained in, or directly or indirectly from, a vehicle accident where you were driving a vehicle involved in the accident and had either:
alcohol in your blood in excess of 80 milligrams of alcohol per hundred millilitres of blood
your ability to operate the vehicle impaired by drugs or alcohol or a combination of the two
medical care which is not medically necessary to treat an injury or sickness or which is of a cosmetic nature. The donation of an organ or tissue will be considered necessary medical care, or
any injury or sickness for which a third party is, or may legally be liable, except as provided for under the third party liability provision in the policy.

When to submit an LTD claim

Co-operators Life must receive written notice of a claim for monthly benefits within 60 days from the end of the elimination period.

Failure to furnish proof within this time will not invalidate nor reduce any claim if it is shown not to have been reasonably possible to furnish the proof and that the proof was furnished as soon as was reasonably possible, but in no event will this be more than 180 days from the end of the elimination period.

If you are totally disabled and receiving benefits under any worker’s compensation legislation or similar statute, you should still submit an application for long-term disability benefits to Co-operators Life according to the above procedure. You may also be eligible to receive Canada Pension Plan (CPP) or Quebec Pension plan (QPP) disability benefits. Applications can be obtained from your nearest CPP or QPP office.