Ask Your Local

Ask the Local: Medical Illness

Question: A few years ago, my doctor diagnosed me with a medical illness that the insurance company would not approve. That decision was appealed twice and, finally, a last appeal confirmed the Industrial Alliance decision to deny benefits. During the process, a new medical claim was filed and denied. The complication is that during the ensuing period of time, my diagnosis changed, but the insurance company refused to allow the original diagnosis to change on the original claim. My employer has been fair and I have returned to work at various times with accommodations, but the illness is wearing me down and I know that there is no way I can continue to work. I am upset that the insurance company refused to allow the original claim to be altered and that I lost the financial support from my policy for the past 3 years. I don’t know what to do next.

Answer: The appeal process for claims filed with the Industrial Alliance is different than with Sun Life. The major difference is that clients of the Industrial Alliance are represented by the Treasury Board of Canada during the appeal process. Once the final appeal is denied, there is little (if anything) that can be done to change the decision. In order to submit a new medical claim and have the likelihood of it being approved, the following criteria (at a minimum) must be met:

• The employee must return to work on a full-time basis for at least 30 consecutive days and then submit a new claim with new medical information;

• The qualifying period of 90 days or 13 week would apply again before any Long Term Disability (LTD) benefits would be paid if approved.

• The past must be the past and, in my opinion, the years of lost financial compensation cannot be regained. The claim that was re-submitted and denied while the first claim was under review or appeal, probably did not meet the criteria as indicated above.

For specific case information, you would be well advised to consult with a Human Resources advisor.

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