The Forum by Realize

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Jill – a Case Study

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Jill in this story is not a real person, but her story is real, and it captures the reality of thousands of Canadians with episodic disabilities.

Jill is a 50-year-old woman who has been working for over 25 years. 7 years ago, she was diagnosed with rheumatoid arthritis. As a result of prompt diagnosis and good management, Jill was symptom-free until last year.

Over the past year, Jill begun to experience flare-ups of her arthritis that are unpredictable and last from a few days to, (more recently), a month. Sometimes Jill can work for a few months or more without an episode.

Although Jill only gets 10 sick days a year from her employer, one arthritis episode can use up all her sick leave entitlement. Jill’s doctor cannot promise that her arthritis could be more consistently managed as the condition is not predictable.

Last month, Jill had no choice but to quit her job and go on disability income support. Her employer had offered her a casual part-time position, but Jill is a single woman, and the part-time income would not support her needs, especially since her medications are costly.

Jill is now out of the workforce, on disability income support and not paying employment-related taxes. Her current income support does not enable her to contribute to the Canadian economy. However, if Jill were able to use Employment Insurance Sickness Benefits more flexibly and over a longer period, instead of the current 15 consecutive weeks or 75 full days, she would be able to stay engaged in the workforce, have access to her employer’s benefits plan and continue to pay income tax and Employment Insurance premiums.

At present, the “all-or-nothing” nature of most disability income supports leaves many people with episodic disabilities with no realistic alternative other than to resign themselves to being classified as ‘disabled’; and leave the workforce. This example above demonstrates how a modest change to Employment Insurance Sickness Benefits would keep many people employed, and result in a more efficient and effective program leading to better use of resources. This is not about more; it is about different.

Factsheet: Action Items for Consumers

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Episodic Disabilities and Insurance: Action Items for Consumers

Are you a person living with HIV, MS, Arthritis, or another health condition that causes you to experience episodic disability (disability that comes and goes)? Are you eligible through your employer for health benefits and Short-Term (STD) or Long-Term Disability (LTD) Insurance?  These benefits can assist you in managing your health, but they can also be challenging to access for people with recurring and unpredictable conditions.  Here are some helpful suggestions.

Find out what is in your health benefits and STD and/or LTD plans.

Many people don’t find out what is in their plan until they need to access it. Be proactive and ask for a copy of your plan ahead of time, so you’ll be prepared and knowledgeable when you need it.

Engage with your available supports.

If you need more information or advice, ask for help from Human Resources or a similar administrative office. If you are unionized, your union representative is a good place to start with any questions you may have related to health benefits or insurance coverage.

Take a preventative approach.

Some of the things in your plan can help prevent episodes – find out what you are entitled to and use it to help you manage your episodic disability. For example, some health benefit plans allow for visits to massage therapists or mental health specialists. If you are entitled to these benefits and they would be helpful for you in managing your condition, access them.  Note, some of these services require a referral from your physician.

Provide feedback to your employer on the usefulness of the plan.

There are some insurance plan elements that can be particularly helpful for people living with episodic disabilities, as they make it easier to transition on and off claim. If you find that you are frequently moving on and off claim, you may want to talk to your employer to see if any of the following could be added to your plan:

A Recurrent Claims Clause

A recurrent claims clause allows for an individual to qualify for STD or LTD based on a reoccurrence of an established and qualified disability taking place within a specified period of time. Recurrent claims clauses are useful in that the new episode is treated as the same as the last episode and the individual is not then required to submit a new claim. There are usually time limits on these clauses; some limit the recurrence period to 6 months.

A Waiver of Elimination Period

In offering LTD, it is possible to request a Waiver of the Elimination Period. This essentially allows for an individual with a recurrent disability to qualify for support during an episode without the requirement of fulfilling a new waiting or elimination period. There are reports of elimination periods that extend for up to 5 years allowing for individuals experiencing recurrent periods of disability to immediately qualify for claim.

Remember, being prepared is an important part of self-advocacy. For more information on episodic disabilities please visit the Realize website.

Disclaimer: This fact sheet is provided for information only. Please consult with your insurance provider directly for details relevant to your unique circumstances.

Factsheet: Action Items for Employers

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Episodic Disabilities and Insurance: Action Items for Employers

Are you an Employer who offers private health insurance like Short Term Disability (STD) or Long-Term Disability (LTD) as part of your employee health benefits? Do you want to improve the coverage or services you get for employees living with unpredictable and recurring episodic disabilities related to MS, Arthritis, HIV, or other health conditions?

Below are steps you can take to improve how these services support your employees:

  1. Challenge your insurer to give you some better options for managing episodic and/or chronic disabilities through STD/LTD program. Ask them to investigate options for you.
  2. Ask your insurer to give you options for those employees who require specialized medication in order to allow them to work (for example, biologics). Discuss whether the cost of the medication may be less than the employee going on STD when symptoms get unmanageable.
  3. Ask your insurer to give you more options for rehabilitation or paramedical care for those employees who live with episodic disabilities. Services such as chiropractors, naturopaths, massage therapists, osteopaths and acupuncturists can be critical to the health of employees living and working with episodic disabilities.
  4. Imposed limits of $500 per rehabilitation practitioner are hard to stick to particularly when consistent care by one practitioner is important. Instead:
    1. Ask for an option for employees to go to one practitioner to a max of $2000.
    2. Or ask for an option for employees for one practitioner to a max of $1000 at 80% reimbursement and then for anything between $1000 and $2000, a reimbursement of 60%.
    3. Or find other creative ways of problem solving.
  5. Adjust perceptions that being “away from work” is always better. Research shows that the less time spent away from the workplace, the more likely the employee will return to full time work.
  6. Ask your insurer to provide options for part-time workers to be able to access specialized drugs or specialized treatments for episodic conditions.
  7. Small businesses can ask insurers to provide options for access to “At Work Services” to assist vulnerable employees to stay at work.

Remember, there is room to tailor your plan to better meet your needs. Talk to your insurance provider today!

For more information on episodic disabilities please visit the Realize website.

Disclaimer: This Fact Sheet is provided for information purposes only. Please consult with your insurance provider directly for details relevant to the unique circumstances of your workplace.

 Copyright Realize 2017

Factsheet: Action Items for Insurers

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Episodic Disabilities and Insurance: Action Items for Insurers

Are you a private health insurance provider encountering challenges related to supporting employees living and working with unpredictable and recurring episodic disabilities? Would you like to improve the affordability and efficacy of your services to this key population? Read on for action items you can take to improve services for this growing demographic:

  • Conduct internal actuarial analyses to answer the question “Are there more efficient ways to manage episodes of illness for employees living with episodic disabilities?”
  • Consider whether a specific “episodic disability leave” option that does not use the same criteria as short-term disability (STD) or long-term disability (LTD) is possible.
    • For example, could someone living and working with an episodic disability have access to 6 months of intermittent time during a period of 24 months, which would count as STD and then any time after would be treated as LTD? This would eliminate the administrative costs of opening and closing cases per episode and would activate At Work Services more quickly for employees who can stay at work during their episode.
  • Is there a different definition for “disability” that would work better when there are unpredictable periods of illness and wellness?
  • Is there a different definition for “return to work” that would make more sense for employees whose capacity can fluctuate from day to day or week to week depending on their symptoms?
  • In evaluating whether someone is totally disabled from the workplace, can the focus be on capacity as opposed to disability?
  • Engage your clients to develop more appropriate administrative processes from the perspective of employers and HR departments.
  • In order to get a better idea of the impact that STD/LTD leaves on the organization, encourage employers to implement business line reporting when implementing a STD/LTD program. This will assist in clarifying what associated costs may be.
  • For small businesses that cannot afford full STD/LTD programs, offer “At Work Services” that assist vulnerable employees who are living through an episode to stay at work or offer “Advice to Pay Services” that can be activated as needed when an episode becomes too difficult to manage at work.

For more information on episodic disabilities please visit the Realize website.

Disclaimer: This Fact Sheet is provided for information purposes only.

Copyright Realize 2017                        

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