Medical conditions and LTD benefits.

You may be wondering which are the medical conditions that qualify for disability benefits? The truth is that any medical condition may potentially qualify for disability benefits. The analysis focusses on the extent of the functional disability caused by the medical condition, and whether the extent of functional disability meets the requirements for various disability benefits plans and programs.

Which medical conditions qualify for disability benefits?

Any medical condition may qualify for disability benefits. Generally speaking, most disability benefits programs in Canada do not give benefits based on a medical diagnosis. Rather, they provide disability benefits based on the degree of disability caused by the medical condition. So the focus will always be on the extent of functional disability caused by the medical condition, rather than only the name of the medical condition or diagnosis. To qualify for disability benefits, an insured must show that the level of disability from the medical condition meets the eligibility criteria of the disability benefits plan in question.

Which medical conditions qualify for short-term disability?

To qualify for short-term disability a medical condition must prevent the insured from performing regular job duties. The insured must show how the symptoms or impairments from the medical condition interfere with the ability to perform those regular job duties.

To do this the insured will need to have an official list of job duties. That list can be reviewed by a family doctor review to confirm an inability to perform the majority of these duties because of the medical condition.

Most short term disability plans will require the insured to be continuously disabled for 7 days or so before qualifying for disability benefits. This is called a waiting period or elimination period.

Following is an example of typical wording of the disability requirement for a short-term disability plan. Please note this is only an example, the exact wording is different for each plan:

An employee is entitled to payment of a short-term disability benefit if that employee proves that:

  • the employee became totally disabled while covered
  • the total disability has continued beyond the elimination period
  • the employee has been following appropriate treatment for the disabling condition

An employee will be considered totally disabled while the employee is continuously unable due to an illness or injury to do the essential duties of the employee’s own occupation in any setting.

Which medical conditions qualify for long-term disability?

Most medical conditions may qualify for long-term disability. However, some long-term disability plans will exclude certain medical conditions.

Assuming disability does not flow from an excluded condition, the insured may qualify for long-term disability benefits if the medical conditions prevents the insured from doing the essential duties of the insured’s regular occupation. The insured will not qualify to apply right away. Most long-term disability plans require the insured to be continuously disabled for a number of weeks before being eligible to apply. This called the waiting period or elimination period.

The most common length of the waiting period is 17 weeks, but this can be different for each disability plan.

Most long-term disability plans have a two tier requirement for disability. For the first 2 years an insured may qualify for long-term disability benefits if the medical condition prevents the insured from performing the essential duties of the insured’s own occupation.

After 2 years the insured may only qualify for long-term disability benefits if the medical conditions prevents the insured from performing the essential duties of any commensurate occupation..

Following is an example of a long-term disability requirement found in a group long-term disability plan. This is only an example and these requirements and wording vary from plan to plan.

An employee is entitled to payment of a long term disability benefit if the employee presents proof of claim acceptable that:

  • the employee became disabled while covered
  • total disability has continued beyond the elimination period
  • the employee has been following appropriate treatment for the disabling condition

An employee will be considered totally disabled:

  • while the employee is continuously unable due to an illness to do the essential duties of the employee’s own occupation, in any setting, during the elimination period and the following 24 months, and
  • afterwards while the employee is continuously unable, in any setting due to illness to do any occupation for which the employee is or may become reasonably qualified for by education, training or experience.
  • The availability of work for the member does not affect the determination of total disability.