Short Term Disability

New insured plan effective January 1, 2017

The ELCIC Group Benefits Plan includes a professionally managed care disability program.

coverage provided by Co-operators Life Insurance

Benefit Amount

The amount of insurance for which any Employee is covered under this Policy is a weekly taxable benefit at 65% of the Employee’s Weekly Salary to a maximum Weekly Benefit of $1,875 rounded to the next highest $1.00 if not already a multiple thereof.

While benefits are payable to an insured Employee under this Policy Co-operators Life will also pay an amount equal to 15% of the pre-disability Salary.

A change in the amount of an Employee’s insurance due to a change in classification, Salary or insurance schedule, shall take effect automatically on the date the increase is received provided written notification is received by Co-operators Life within 31 days of the change and premiums are paid on the increased amounts. When an Employee is entitled to a retroactive incrase, a change in the amount of insurance shall be made the date the Employee actually recived the increase, provided the Employee is Actively at Work on that date. If the Employee is not Actively Working the insurance will not be increased until the Employee returns to Active Work.

Overall Maximum

At the time of a claim and throughout the claim, the applicable Weekly Benefit as determined in the Policy will be limitied to an Overall Maximum of 100% of the Weekly Salary for which the Employee was insured immediately prior to the start of Total Disability.

Rehabilitation Program

“Rehabilitation Program” is a program provided to an Employee at the sole discretion of Co-operators Life. A Rehabilitation Program may include Rehabilitation Assessment and/or Rehabilitative Employment and/or Rehabilitative Treatment and/or Rehabilitation Services recommended and approved by the Co-operators Life. The duration of a Rehabilitation Program must be approved by Co-operators Life.

“Rehabilitation Assessment” may be a medical and/or psychological and/or vocational evaluation of an Employee’s rehabilitation potential and, where deemed appropriate by Co-operators Life, to establish an appropriate rehabilitation program.

“Rehabilitative Employment” is a work trial, which may be full-time , part-time or modified work.

“Rehabilitative Treatment” is medical and/or psychological and/or vocational intervention designed to assist the Employee to return to Active Work and includes, without limitation, vocational and physiotherapy programs.

“Rehabilitative Services” can involve training strategies or work related activities that can be expected to enhance to Totally Disabled Employee’s abilitiy to secure employment or to return to Active Work at the Employee’s own occupation or other gianful employment and may be limited to assistance with resume preparation and job search.

Approval of Rehabilitation Program

Co-operators Life shall have sole discretion in determining whether or not a Rehabilitation Program is appropriate and/or provided for any Employee.

Once the Rehabilitation Program is approved, Co-operators Life may issue, if eligible, Weekly Benefits to a Totally Disabled Employee who continues to participate and co-operate in an approved Rehabilitative Program.

The Rehabilitation Program wil not extend beyond the end of the Employee’s Short Term Disability Benefit payment period unless an extension of the duration is recommended and approved in writing by the Co-operators Life.

Calculation of Weekly Benefits during a Rehabilitation Employment Period

Where the Employee participates in Rehabiliative Employment approved by Co-operators Life, the applicable Weekly Bnefit will continue during the period of Rehabilitative Employment, but will be reduced by 50% of the Rehabilitative Earnings. “Rehabilitative Earnings” means the total earnings from Rehabilitive Employment.

The Weekly Benefit may be further reduced by any amount necessary to reduce the total income the Employee receives from all sources to 100% of the Weekly Salary for wich the Employee was insured immediately prior to the start of Total Disability.

Benefits will cease on the earliest of:

  • the date the Employee refuses to participate or co-operate in any Rehabilitation Program recommended or approved by Co-operators Life including but not limited to any Rehabilitation Program offered through: any worker’s compensation act or similar statute, Auto Plan Benefits or Canada Pension Plan, or
  • the Withdrawal of Co-operators Life’s approval of an Employee’s Rehabilitation Program.

None of the preceding will be construed to extend the period that any Employee would have been entitled to benefits due to Total Disability had the Employee not participated in the Rehabilitation Program.

Employee Weekly Income Benefit

If an Employee insured under this coverage become Totally Disabled and the Total Disability results in a loss of income and if satisfactory proof is received by Co-operators Life, Co-operators Life will subject to the provisions of this Policy, make payments to the Employee at the rate of the Weekly Income Benefit for which the Employee is then insured, while the Employee remains so disabled. Notwithstanding the terms of the Recurrent Disability provision, no Weekly Income Benefit shall be paid beyond:

  1. the date the Employee ceases to be Totally Disabled, or
  2. the date of the Employee’s 65th birthday. However, an Employee that is Totally Disabled on this date shall be entitled to fifteen (15) weeks of benefit payments after the completion of the elimination period, subject to all other terms and conditions of the provision, or
  3. the date of death of the Employee, or
  4. the date the Employee engages in any occupation or performs any work of any sort for wage, remuneration or profit, or
  5. the date Co-operators Life deems the Employee to have failed to furnish evidence of continuance of Total Disability satisfactory to Co-operators Life, or
  6. retirement or normal retirement date as determined by the Employer or the date the Employee withdraws or elects to receive pension funds, whichever first occurs, or
  7. the date the Employee refuses to submit to a Medical Examination by a Physician chosen by Co-operators Life,

whichever first occurs.

In no case shall the benefit be paid for more than 17 weeks from the date of disability for any one period of Total Disability, whether for one or more causes, not shall the Weekly Income Benefit payment exceed 65% of the Employee’s earnings.

Benefits payable for periods of disability of less than a full week shall be paid at the rate of one-seventh of the applicable weekly benefit for each working day of Total Disability.

Elimination period

Benefits for Total Disability as a result of Injury or Sickness will commence on the 15th consecutive day of Total Disability.

Benefits for Total Disability as a result of the Employee being hospitalized shall be payable from the 15th full day of Total Disability. For the purposes of this benefit, hopitalization shall mean confinement as an inpatient for a period of at least twenty-four (24) hours.

Total Disability Waiver of Premium

If a Totally Disabled Employee is also insured for Long Term Disability Benefits under this Policy and a claim for Long Term Disability Benefits is approved, premiums for Short Term Disability Benefits will be waived effective the same date as the premiums for Long Term Disability Benefits are eligible to be waived.

Recurrent Disability

If, following a period of loss of earnings for which benefits had been paid under this Policy, the Employee returns to work for a period of four consecutive weeks and suffers no further loss of earnings during this time, any further period of Total Disability and loss of earnings due to the same or related cause will be considered as resulting from a new Injury or Sickness and the full term of benefits and elimination period will be restored.

If following a period of loss of earnings for which benefits had been paid under this Policy, the Employee returns to work for a period of less than four consecutive weeks and then becomes Totally Disabled again due to the same or a related Injury or Sickness, the Total Disability shall be treated as a continuation of the previous period of Total Disability.

Third Party Liability

Where an Employee becomes Totally Disabled as a result of an Injury or Sickness for which a third party is or may be, directly or indirectly, either in whole or in part legally liable, no benefits will be paid under this Policy unless the Employee:

  1. agrees to repay the Insurance Company the full amount of the benefits paid or to be paid (the “T.P. Benefits”) less such amount the Insurance Company, in its sole discretion, agrees to allow for legal fees, and
  2. takes all steps necessary to recover from the third party the total of the T.P. Benefits advanced or to be advanced under this Policy, including without limitation, directing the Employee’s lawyer to repay the Insurance Company the full amount of the T.P. Benefits paid directly from any monies received from any judgement or settlement, and
  3. enters into a Reimbursement Agreement with the Insurance Company outlining the terms and conditions under which the T.P. Benefits are to be repaid, and
  4. the Employee must obtain the written consent of the Insurance Company before compromising or settling the action or cause of action with the third party. Failure to obtain the consent of the Insurance Company will disentitle the Employee to future benefits under this Policy and will relieve the Insurance Company of all of its obligations to the Employee under this Policy. Consent shall not be reasonably withheld by the Insurance Company.

Income from Other Sources

In this Provision:

“Government Plan Benefits” means any benefits which, as a result of Injury or Sickness, are payable to an Employee directly or indirectly form any government agency to replace income and includes without limitation any benefits which the Employee has received or is entitled to receive under the Canada Pension Plan, Quebec Pension Plan, any worker’s compensation act or similar statute or any Criminal Injuries Compensation Legislation.

“Auto Plan Benefits” means any benefits which, as a result of an automobile accident, are payable to an Employee to replace income, whether payable by a government run plan or a private insurer and includes without limitation benefits which the Employee has received or is entitled to receive under any provincial motor vehicle accident insurance plan if the benefits payable under the Employment Insurance act are not taken into account when determining the amount of benefits payable under the provincial plan, including without limitation the Manitoba Public Insurance Corporation Act and the Saskatchewan Automobile Accident Insurance Act.

“All Source Benefits” means:

  • the total amount of compensation which, as a result of Sickness or Injury, the Employee has received or is entitled to receive from any source including without limiting compensation received from any:
    • pension plan,
    • Employer funded salary replacement,
    • other insurance plan whether group or association,
    • Government Plan Benefits,
    • Auto Plan Benefits,
    • damages paid or payable from any legal action except thsoe damages which Co-operators Life in its sole discretion deems to be compensation for a loss other than a loss of income, and
  • any compensation which the Employee receives while employed or while performing work of any sort, and
  • any payment made by the Employer to the Employee as a result of the termination of the Employee’s contract of employment, and
  • any CPP/QPP retirement benefits the Employee applies for and receives after the date of Total Disability.

“Salary” means the amount of salary for which the Employee was insured immediately prior to the start of the Total Disability.

Direct Deduction

Where an Employee is Totally Disabled, the amount of Weekly Benefit payable will be reduced directly by the amount of any Government Plan Benefit and/or Auto Plan Benefit which the Employee is receiving or is entitled to receive, excluding any benefits payable as a result of the Employee’s marital or dependent status. Any Weekly Benefit payable to an Employee shall not be further reduced as a result of any cost of living increases provided after commencement of disability benefits under any Canada or Quebec Pension Plan benefits.

Indirect Reduction – All Source Maximum

The following limitation shall apply to the amount of benefits payable under this Policy to the Employee. This limitation overrides any obligation of Co-operators Life to pay benefits to the Employee under this Policy. Benefits payable under this Policy will be reduced according to the following formula:

Benefits payable = 100% of Salary minus the All Source Benefits.

Where an Employee does not qualify for any portion of the All Source Benefits because of failure to apply (or appeal where so advised by Co-operators Life) in a timely and satisfactory manner, Co-operators Life reserves the right to reduce the amount of insurance payable by the amount of All Source Benefits for which the Employee would have been eligible had a proper application or appeal been made.

If the Employee receives or has the option of receiving part or all of the All Source Benefits as a lump sum payment, the benefit payable under this Provision will be reduced as follows:

  1. if the Employee has the option of receiving the payment as a weekly payment, the benefit payable will be reduced as if the Employee had elected to receive a weekly payment, or
  2. if the Employee had no option of receiving the payment as a weekly payment, the lump sum payment will be converted into a weekly payment using the following formula:

F=LS/WB

F=Factor based on the number of weeks for which Co-operators Life deems the lump sum payment to have been made.

LS=Lump Sum Payment.

WB=Weekly Benefit

Nothing is this provision shall prevent Co-operators Life from recovering any over-payment of benefits paid under this Policy which may arise as a result of a lump sum payment of the All Source Benefits which, if it have been paid in instalments or had been paid beginning at the date the Employee became eligible to receive such a benefit would have resulted in a reduction or cessation of benefit here-under.

Limitations and Exclusions

No amount of Weekly Income Benefit will be payable under this Policy for Total Disability directly or indirectly due to or resulting from any one or more of:

  • insurrection, war (whether declared or not), civil riot or commotion, regardless of whether the Employee was actually participating therein, or
  • committing, attempting or provoking an assault or a criminal offense, including alcohol in his or her blood in excess of 80 milligrams of alcohol per hundred millilitres of blood; or
  • use of drugs or alcohol unless you are being actively supervised by and receiving continuous treatment from a rehabilitation centre or an institution provincially recognized for that treatment and approved by Co-operators Life, or
  • Medical Care that is cosmetic in nature and not required due to Injury or Sickness or Medical Care that is not medically necessary to treat an Injury or Sickness. Periods of Total Disability due to the donation of an organ or tissue will be considered as necessary Medical Care. Periods of Total disability due to Medical Care that is not medically necessary will be eligible for benefits if the period of Total Disability extends beyond 14 days from the initial date of Total Disability. Benefits will be payable commencing on the 15th day of Total Disability. This does not apply to any plastic surgeries performed solely for cosmetic reasons, or
  • any Injury or Sickness for which a Third Party is or may legally be liable, except as provided for in the Third Party Liability provision.

No Weekly Income Benefit will be payable under this Policy for any period while the Employee is:

  • not under the continuing care and treatment of a Physician considered appropriate by Co-operators Life, or
  • imprisoned, or
  • on Maternity Leave, Parental Leave or any other leave of absence.

No further benefits will be payable from the date the Employee refuses to participate or co-operate in any Rehabilitation Program recommended or approved by Co-operators Life including but not limited to any Rehabilitation Program offered through: any worker’s compensation act or similar statue, Auto Plan Benefits or Canada Pension Plan or the date Co-operators Life withdraws approval of an Employee’s Rehabilitation Program.

Claims

Notice

Written notice of Injury or Sickness, upon which a claim may be based under this section must be given to Co-operators Life at its Office in Regina, within 30 days of the date of occurrence.

Failure to give notice within this time shall not invalidate nor reduce any claim if it is shown not to have been reasonably possible to give notice and that notice was given as soon as was reasonably possible.

Forms

Please contact ELCIC Group Services for forms

Co-operators Life, upon receipt of notice, will furnish the forms for Proof of Loss. If these forms are not furnished within 30 days of the receipt of notice, it shall be deemed that the claimant has complied with the Proof of Loss requirements of this Policy when written proof covering the occurrence, character and extent of loss for which a claim is made is submitted within the time fixed in this Policy for filing Proof of Loss.

Proof of Loss

Written Proof of Loss must be furnished to Co-operators Life at its Office in Regina. In the case of a claim, proof must be furnished within 90 days form the date Co-operators Life is liable and subsequent written proof of the continuance of Total Disability must be furnished to Co-operators Life at such intervals as Co-operators Life may reasonably require.

Failure to furnish proof within this time shall not invalidate nor reduce any claim if it is shown not to have been reasonably possible to furnish the proof and that the proof was furnished as soon as was reasonably possible, but in not event shall this be more than 12 months after becoming eligible.

Time of Payment

Subject to due Proof of Loss, benefits shall be paid as agreed to by Co-operators Life and the Employer during any period for which Co-operators Life is liable. Any balance remaining unpaid on the termination of this period will be paid immediately upon receipt of due proof. All other benefits, if any, provided in this Policy will be paid within 30 days of receipt of proof thereof.

Extension of Time

If any time limitation of this Policy with respect to giving notice of claim or furnishing Proof of Loss is less than that permitted by the law of the Province in which the insured Employee resides at the time of becoming insured under this Policy, such limitation is hereby extended to agree with the minimum period permitted by law.

Medical Examination

Co-operators Life shall have the right and opportunity to conduct any investigations relating to applications or claims and to obtain independent medical or vocational assessments of any Covered Person, as often as it may reasonably require.

Limitation of Actions

Except where or when applicable legislation permits the use of a different limitation period, every action or proceeding against an insurer for the recovery of insurance money payable under the contract is absolutely barred unless commenced within the time set out in the Insurance Act or any other applicable legislation.

Where or when applicable legislation permits the use of a different limitation period, no action or proceeding at law or in equity shall be brought against Co-operators Life for payment of benefits under the Policy or for any other related damages:

  • prior to the expiration of 60 Days after the claim form has been filed in accordance with the requirements of the Policy: or
  • unless brought:
    • where no benefits have been paid, within one year from the expiration of the time within which the claim form is first required (see Notice provision) by the Policy or from the date on which Co-operators Life first denies the claim for benefits, whichever first occurs; or
    • where benefits have been paid under any provision of the Policy, within 1 year of the date on which Co-operators Life terminates payment of such benefits.

The time limit within which to commence an action shall expire on the date(s) as specifically provided for in this provision and in no event shall it be extended to each and every monthly payment accruing after the date(s).