Teachers and support staff in Ontario may be entitled to coverage under the Trustees of the Ontario Insurance Plan (“OTIP”). As of January 1, 2020, the Trustees of the Ontario Teachers Insurance Plan (OTIP) assumed management of the long-term disability benefits plan which was previously insured under Manulife Financial. The plan is now self-insured which means benefits are paid for and managed by OTIP.
If a long-term disability benefits claim was submitted prior to January 1, 2020, it will fall under the prior OTIP/Manulife regime where claims and appeals were adjudicated by OTIP and Manulife.
When you appeal a long-term disability benefits denial or termination under the new regime, the Appeal Committee consists of the case manager/disability analyst with a senior quality assurance representative from OTIP and a medical doctor. Manulife no longer has any involvement in adjudication of new claims submitted as of January 1, 2020.
Teachers and support staff who are submitting or have submitted a claim for disability benefits should be aware that there are nuances associated with the OTIP plan and the OTIP claims adjudication process.
Firstly, the tests for disability under the new plan are very specific. The plan currently states:
“During the initial assessment period, as shown in the Table of Benefits, a Covered Member is considered Disabled if, because of illness or injury, the Covered Member is unable to perform the significant duties pertaining to their Specific Assignment.
If illness or injury prevents the Covered Member from performing a duty, it will also be considered to prevent the Covered Member from performing: 1. other duties that are performed only in order to complete that duty; and 2. other duties that can only be performed after that duty is completed. After the Initial Assessment Period
After the initial assessment period, a Covered Member is considered Disabled if illness or injury prevents the Covered Member from being Gainfully Employed.”
This wording is unique to the OTIP plan and understanding how to interpret and apply the wording to your specific medical situation, your assignment and employment situation is an important skill set for your lawyer.
Whether you require assistance with the application process, an appeal or litigation, intimate knowledge of the adjudication process under the OTIP plan is critical.
Understanding the goals of the Early Intervention Services and what their mandate is may facilitate a greater understanding of how to navigate ongoing communications with OTIP.
During the course of your claim, you could be dealing with your employer (your School Board) and your benefits provider (OTIP) at the same time. Determining what information should be provided to each entity and the roles played by each entity is essential.
Even if you have sought the assistance of your Union or, you have been assigned a Senior Disability Service Representative, that does not prevent you from speaking with a lawyer outside of your Union and OTIP to ensure that you have an understanding of your rights and that your rights are protected.
When it comes to starting litigation against OTIP for the termination or denial of your benefits, there is an important interplay between your disability benefits and pension contributions that is integral to ensuring that you are appropriately protected.
We have significant experience dealing OTIP disability claims. If you have a question related to the application, appeals or litigation process, please contact our office.
