Does complex regional pain syndrome qualify as a disability in Canada?
Complex regional pain syndrome is considered a disability in Canada due to the constant pain that diminishes one’s quality of life. The constant symptoms of complex regional pain syndrome can make finishing even straightforward tasks a challenge, so it falls under the umbrella of conditions that qualify for disability benefits within Canada. Unfortunately, it can be challenging to make insurance providers recognize and acknowledge your situation.
Medical professionals think that the root cause stems from your central and peripheral nervous systems interacting poorly or improperly, stimulating strange inflammatory responses in your body. Since this isn’t a prevalent disorder, it’s not fully understood by modern medicine. Although it is unquestionably disabling, it can be tricky to present a well-rounded claim to your insurance provider to receive the benefits you’re legally entitled to. A disability lawyer is essential in building your claim, filling in those holes, and providing you with an air-tight suit.
Employment and disability rights for complex regional pain syndrome
In Canada, any person who has a disability has the right to a discrimination-free workplace. The employer also has a duty to accommodate their employee. Employers may indeed fire anyone with proper notice and reasoning. However, they cannot fire you for a discriminatory reason regarding your complex regional pain syndrome. If the symptoms of CRPS become too severe for you to continue working, then a leave of absence is not an unreasonable request. Most employers will not object to this if the employee provides a doctor’s note.
The note should state the need for time off and the amount of time required. If this is a prolonged absence, the employer may request that a doctor’s note be resubmitted every three to six months. During this time, the individual has a right to submit their claim for long term disability benefits. If the claim is denied, the employee may stay on a leave of absence and appeal.
Termination due to a disability or medical condition counts as discrimination. In this case, the individual is entitled to severance pay. The decision may be reversed in some cases, and the employee can return to work if they wish.
Types of disability rights for complex regional pain syndrome
Not all disability insurance plans are the same. Here are the typical benefits included in Canadian disability insurance plans:
Paid Sick Leave
Some workers will have a bank of sick time to use in the first days of disability. The intent of this benefit is to allow the worker to have a few days to get back to work. Some workers may have many weeks or even months of accrued time to use.
If you do not believe that you will be able to return to work before your paid sick leave is exhausted, be sure to complete an application for disability insurance benefits right away. You do not need to wait until you have used all your paid sick leave before submitting your application. Also, it is always easier to work on a disability application while you are being paid so don’t wait until your benefits have run out.
Another major reason not to wait to apply for STD Benefits is because of deadlines that may apply. You may miss the deadline to apply for benefits because you are being paid sick leave benefits.
Employment Insurance Sickness Benefits
Your alternative to paid sick leave is government provided employment insurance (EI) benefits. Most workers have fewer than 15 weeks of paid sick leave so EI benefits will make up the difference between the expiry of paid sick leave and a STD Benefit. EI Benefits must be applied for through the government. In order to apply, you must obtain a medical report from your doctor and a Record of Employment (ROE) from your employer.
Go to www.servicecanada.gc.ca for information on the EI sickness benefit and to download the application forms. Service Canada will not process your application until both the medical form and the ROE has been submitted, so be sure to book a doctor’s appointment and request your ROE right away.
Short-Term Disability Benefits
The first of two main benefits in most disability benefit plans are STD Benefits. The purpose of STD Benefits is to provide you with income while you are unable to work due to illness or disability. The Benefit is designed to cover short absences and not intended to be a long-term solution.
STD Benefits provide a weekly or bi-weekly payment for a number of months. The short pay periods are designed to provide you with uninterrupted income while you are absent from the workplace. Most often, you will be required to use accrued paid sick time before accessing your STD Benefits. While cashing in sick time may be frustrating for some, it is wise to accept this condition because the sick time should provide you with more income than the STD Benefit.
The STD payment typically provides for a percentage of your regular weekly earnings or a specific amount of money. The benefit payment calculation details are specific to the policy and set out in the insurance policy document.
Payment examples include:
• The worker will be paid 60% of his or her pre- disability weekly earnings, or
• The worker will be paid $500 per week, or
• The worker will be paid their pre-disability weekly earning, up to a maximum of $500 per week.
Most STD Benefits last between three and six months. If the group plan does not have a LTD Benefit, the worker will have no further benefits under the group policy.
Long-Term Disability Benefits
LTD Benefits are the second major element of most group disability plans. There are some plans, however, that only include LTD Benefits. If your plan has both STD and LTD Benefits, a disabled worker will ‘roll over’ to the LTD Benefit at the expiry of the STD period if they are eligible to do so.
Eligibility for LTD Benefits is not always a given. Workers often earn their eligibility to the Benefits through working continuously for the employer for a number of months.
Eligible workers will be able to make a claim for LTD Benefits if they have been out of work continuously for a specific period of time. This period of time is typically the length of the STD Benefit. This period of time set out in the policy wording is referred to as a “waiting period” or “elimination period”. LTD Benefits will not be paid prior to the elimination period; however, benefits will be paid for the total period of continuous disability if the claim is approved.
Benefit payments under a LTD Benefit are assessed based on a percentage of your pre-disability income. Typically, the benefit will be between 55% and 75% of your regular earnings, or a set amount of money per month. Other polices will have a net formula.
Payment examples include:
• The worker will be paid 66.7% of their monthly pre-disability earnings, or
• The worker will be paid $3,000 per month, or
• The worker will be paid 66.7% of his or her monthly pre-disability earning up to a maximum of $3,000 per month.
The exact payment formula will be set out in the policy document. Be sure to refer to your policy to confirm what the applicable payment formula is for your claim.
The LTD Benefit will make payments on a monthly basis for a set number of years (e.g. 5, 10, 20), or until you reach a certain age (e.g. 60, 65, 67). Some plans may have a benefit termination formula where a mixture of the years a claimant received benefits and the claimant’s age is used to calculate an end date. Generally speaking, the latest date where a claimant will be eligible for Benefit payments is called the Maximum Benefit date.
How to win disability benefits for complex regional pain syndrome
The first step to winning your disability benefits claim is to obtain a firm diagnosis and complete any relevant medical testing. Since this condition is caused by the central and peripheral nervous systems not interacting correctly, there is no one test to identify what you’re experiencing as complex regional pain syndrome. It is the patient’s responsibility to cooperate with their doctor and pursue a series of different tests to receive an official diagnosis.
Recording your symptoms in detail is a vital piece of the puzzle. Symptoms may vary but tend to include sensitivity to cold or hot, varying skin temperatures or colours in the affected area, muscle spasms or atrophy, swelling, pain in the joints, changes in skin texture, hair and nail growth, and decreased mobility. In some advanced cases of CRPS, there can be tissue wasting or tightening of the muscles.
Some tests that can help obtain an official medical diagnosis include x-rays, magnetic imaging, bone scans, and nervous system tests. Following your doctor’s recommendations will streamline this process and demonstrate your willingness to cooperate. Eventually, you will be diagnosed with type one or type two CRPS. Type one stems from injury or an illness damaging the nerves within the limb, and type two involves a direct injury of the nerve in the limb.
Once you have secured the diagnosis, it will be a relief and a massive step towards your claim for disability benefits. Although a diagnosis from a doctor is essential, it is only the beginning. Now you must prepare a claim to present to your insurance providers.
A diagnosis proves that you’re suffering from a serious condition, but it’s not enough for an insurance provider. They want to see that you’ve exhausted every effort to maintain regular employment and actively attempting to improve your condition.
Documenting your symptoms, challenges at work, and limitations will help fill any holes in your claim. Did you have a bad day with visible signs in your affected limb? Take pictures or write about it in a journal. No one knows your condition better than you do! If you’re experiencing psychological symptoms, like insomnia due to pain or an inability to focus on work – document that too! The more evidence gathered with your claim, the harder it is for an insurance company to deny.
How to improve your long term disability claim for complex regional pain syndrome
- Full cooperation with medical experts, insurance providers, and anyone else involved in your claim
- Documentation of good days and bad days, and tasks that you were unable to complete at work due to your CRPS
- A full medical file that demonstrates you’ve made every effort to control and minimize the symptoms of your condition
- Honest statements, over-exaggerating your symptoms doesn’t help your claim
How to hurt your long term disability claim for chronic fatigue syndrome
- Contradicting statements or stories regarding your claim
- Aggressive or confrontational attitude towards those working on your claim
- A lack of effort in going to see the doctor, missed appointments, or unfilled prescriptions
Common reasons for denial of CRPS claims
When it comes to disability claims, they are often rejected due to a lack of evidence supporting your inability to return to work. Insurance companies will find any angle or hole within your claim and use it to deny your right to your benefits.
Not having a complete doctor’s diagnosis or a detailed record of treatment are the first things an insurance company will look at and use to deny your claim. Then, even if you have all that in your medical file, you still need to prove that you cannot work.
Insurance companies will look at your employment history to see if you’ve tried different roles or positions. If you’ve been working in a high-impact role that keeps you on your feet but haven’t tried switching to a sit-down position, they’ll exploit this and use it to deny your benefits. Even if you know you’re unable to work, you must show that you’re actively exploring alternatives within the company.
This news can be devastating, and being forced back to work when you need time to heal is scary! Receiving that rejection letter can create even more mental and physical symptoms than what you’ve already dealt with. However – all is not lost. Hiring an experienced disability lawyer to help you fill in the gaps within your claim, and file an appeal, is an excellent step towards receiving the long term disability benefits you are owed.
What if your claim is denied?
Know that you are part of a large group of Canadians who have had their benefits denied by the insurer at some point during the course of a claim. Those who have been issued a denial letter are those who had their application rejected by the insurer. They were deemed eligible to apply for benefits, but not totally disabled and therefore were not approved for benefits. Those who have been issued a termination letter are those who were approved for benefits but were then found not totally disabled. The insurance company generally chooses to terminate benefits at or before the two-year mark from the date of disability.
For those who have been denied, some will be legit mate because the applicant is not in fact disabled. Other applicants are truly disabled but were simply denied by the adjuster because their application was not strong enough to warrant approval. Of course, the insurer would prefer that denied applicants forgo the appeal process and not sue for benefits.
For those who were approved and then cut off sometime afterwards, the insurer is attempting to ensure that the denial is accepted by the insured during the “own occupation” period. This is ideal for the insurer as it may prevent appeals or legal claims. Thus, it allows the adjuster to close the file well before the Change of Definition date occurs.
You cannot change the fact that the insurance company denied your claim. However, you do have complete control over what you do in response to the denial or termination of benefits.
The options available to the applicant will depend on what is permitted by their policy or plan. In most cases, the applicant can advance their claim to an internal appeal mechanism or commence a lawsuit. If a plan is through a non-profit disability benefit trust fund, it is likely that only an internal appeal mechanism will be available to them. For these workers, they have been denied the right to have a neutral court decide whether or not they are entitled to benefits.
WHAT IS THE DIFFERENCE BETWEEN A DENIAL LETTER AND A TERMINATION LETTER?
It is a bad day for any disabled worker when they receive a denial letter or termination letter. The letter is essentially a rejection of financial support in a time of need and it leaves most people very worried about their financial future. After receiving a letter, some disabled people experience severe declines in their mental or physical health because it feels like their expected safety net has been ripped out from beneath their feet.
What the disabled person does after receiving a denial letter or termination letter is critical. First, be sure that you keep a copy of the letter. Photocopy and safely store a copy of the letter before making any marks on the letter. Any competent disability lawyer will want to see a clean copy of the letter to review at an initial meeting.
The denial letter is also important as it offers a window into the insurance company’s decision-making process on your file. The letter should (but does not always) spell out what information was reviewed and what findings were made with respect to the information in your file. The insurer should explain why your application was denied, or why you are no longer entitled to benefits. For new claims, the denial will typically mention that while your injuries cause you to suffer some restriction, you do not meet the test for total disability. For cases where a benefit termination letter is sent, the insurer will often mention that activities (often from surveillance evidence or information from phone calls) are inconsistent with reported restrictions and limitations. The explanation provided in other circumstances will parrot select wording from the medical expert chosen by the disability insurer. Once you have sorted out why you were denied, you can then determine what you can do to attempt to overturn the unfavourable decision.
Warning! There is a lot of misinformation about insurance policies and the rights that come with them. Do not rely on the word of a union representative, co-worker, or supervisor to explain your rights and ideal strategy when facing an insurance benefits claim. This is especially so where there is no right to sue. While they may have the best intentions, they may not have the best advice. Contact an experienced disability lawyer to avoid a major claims mistake.
