Member Benefits

Short Term Disability (Weekly Indemnity)

Payment of Benefits

Upon receipt of proof of claim satisfactory to the benefits provider that:

a member became totally disabled while insured under this benefit and remained totally disabled during the elimination period and
the member is under the continuing medical care of a physician.

The benefits provider will pay weekly indemnity benefits for as long as the member is totally disabled, in accordance with applicable policy provisions, up to the maximum benefit period indicated.

To qualify for weekly indemnity benefits, any accident causing the total disability must be confirmed by a physician and sustained not more than 30 days before the onset of such disability.

The “health-related portion” of maternity leave taken by a member is considered to be a period of total disability for the purposes of benefit payment under this benefit, whether the member’s insurance was continued during the leave or not. The maternity benefits payable under any public or private plan are deducted from the benefits payable to the member for this period in accordance with the provisions of the contract.

For a total disability that begins during the voluntary leave portion of a maternity leave or during parental or family-related leave, benefits are payable from the later of the following dates, provided the current benefit remains in force and provided the member is still totally disabled and insured under this benefit:

the end of the elimination period;
the scheduled date of return to work.

The amount of weekly indemnity benefit payable under this benefit will be the amount specified in the summary of benefits based on the earnings in effect immediately before the commencement of total disability.

The weekly indemnity payments may be taxable in accordance with the summary of benefits. weekly indemnity benefits are payable weekly in arrears, commencing on the later of:

the completion of the elimination period; and
the first day the member consults a physician.

Disability Management

The benefits provider may at any time require a totally disabled member to participate in a disability management program.

The benefits provider will actively co-ordinate all disability management program services listed below and will also facilitate and ensure case follow-up

co-ordination of access to health care services;
support program for returning to work;
negotiations for a gradual return to work; and
a rehabilitation employment program may include evaluation, treatment, training, placement and job search services.

If a totally disabled member, while receiving weekly indemnity benefits, takes part in a total disability management program under the supervision of his physician and with the approval of the benefits provider:

the member will still be considered totally disabled while taking part in this program
if, while taking part in this program, a member becomes totally disabled again, the terms and conditions of the weekly indemnity benefit will apply to the member as if he had been totally disabled during the disability management period
if, as a result of taking part in this program, the member earns any income, the weekly indemnity benefits payable to the member will be reduced by 50% of the amount of income earned from any rehabilitative activity
the maximum benefit period during any period of total disability will continue to apply even if the member is taking part in a disability management program
while the member is taking part in a total disability management program, the benefits provider will reduce their weekly indemnity benefits so that their total income from all sources, as listed in the all source maximum section of this policy, does not exceed 100% of his gross earnings (net earnings if the weekly indemnity benefit is non-taxable) immediately before the commencement of total disability.

A member who refuses to take part in a disability management program or does not participate in such program in good faith will no longer be eligible for weekly indemnity benefits.

Recurrent Total Disability

Successive periods of total disability occurring after the weekly indemnity benefits became payable are considered to be the same period of total disability unless they are separated by at least:

two consecutive weeks of active full-time employment if total disability is due to the same cause or related causes or
1 day of active full-time employment if total disability is due to an entirely unrelated cause.

Whenever successive periods of Total Disability are considered to be the same period of total disability, the elimination period will not be applied a second time, and the same amount as for the initial total disability minus any payments already made will be payable for the remainder of the maximum benefit period.

Reduction of Weekly Indemnity Benefits

Weekly indemnity benefits otherwise payable to the member under this policy will be reduced by:

any benefits the member is eligible to receive under any Workers’ Compensation Act or similar legislation;
any amount the member is eligible to receive under the Canada Pension Plan or the Quebec Pension Plan at the date of total disability, including early retirement benefits, but excluding:
- benefits payable on behalf of his dependents;
- any increase in these benefits after weekly indemnity benefits commence due solely to cost-of-living;
any indemnity payable for loss of time under any government plan requiring or providing automobile insurance benefits on a no-fault basis;
the amount of benefits payable from any other disability income plan, including employer-paid sick leave and disability pension income, but excluding a private disability insurance plan or income received in respect of a previous unrelated disability; and
any net proceeds of a third-party claim. Net proceeds of a third-party claim paid in a lump sum will be subject to the third-party claims provision.

If any direct offsets are paid in a lump sum, weekly indemnity benefit payments will be reduced by the equivalent weekly payment for the number of weeks of disability for which the lump sum is paid.

The benefits provider may also reduce the weekly indemnity benefit payments if the member who is required to make the necessary application fails or refuses to exercise his rights under the above-mentioned legislation or plans.

The benefits provider may, at its discretion, estimate the amount of the government plan award pending notice of the actual award.

All Source Maximum

In addition to direct offsets, weekly indemnity benefits will be further reduced by any amount by which the member’s total income from all sources exceeds the all-source maximum. The total income of a member from all sources, whether he receives or is eligible to receive this income, will include all of the following:

Weekly indemnity benefits under this policy.
Payments under any other program providing disability benefits but excluding the minimum monthly benefit of $50 under policy 64090L, as applicable.
any earnings or payments from the employer or other disability income from any other plan sponsored by the employer, but excluding earnings or disability benefits in respect of any other regular job with the employer which the member was performing before total disability.
any disability benefits under the Canada Pension Plan or the Quebec Benefit Plan, including early retirement benefits, but excluding benefits payable on behalf of dependents and any increase in benefits after benefit payments commence due solely to the cost of living.
any disability benefits payable for the same total disability under any Workers’ Compensation Act or similar legislation or any other government plan, excluding the Employment Insurance Act.
any benefits payable from a retirement or pension plan, excluding any increase in benefits after benefit payments commence due solely to cost of living.
any indemnity for loss of time payable under any government plan requiring or providing automobile insurance benefits on a no-fault basis; and
any net proceeds of a third-party claim. Net proceeds of a third-party claim paid in a lump sum will be subject to the third-party claims provision.

If any of the foregoing is paid in a lump sum, weekly indemnity benefits will be reduced by the equivalent weekly payment for the number of weeks of disability for which the lump sum is paid.

The benefits provider may, at its discretion, estimate the amount of the government plan award pending notice of the actual award.

Limitations And Exclusions

No weekly indemnity benefits shall be payable under this policy for total disability resulting directly or indirectly from one of the following:

intentional, self-inflicted Illness or Injury or attempted self-destruction, whether sane or insane;
Total disability where the member is not under the continuing medical care of and following the treatment prescribed by that physician;
where the member refuses to disclose medical information required by the benefits provider or physicians acting for the benefits provider;
total disability due to illness or injury which occurred after the member was placed on layoff status;
during the imprisonment of the member due to conviction of a criminal offence;
war, whether declared or not or service in the armed forces of any country or participation in a riot, insurrection or civil commotion;
committing or attempting to commit a criminal offence;
cosmetic surgery or treatment, unless such surgery or treatment is required as a result of an accident;
alcohol or drug abuse unless, for such abuse, the member is actively taking part in a therapeutic program supervised by a physician on an ongoing basis, is receiving continuing medical care or treatment for rehabilitation and is staying in an established treatment centre qualified to provide the necessary treatment or care;
driving a motorized vehicle while impaired by drugs or with an alcohol level that exceeds the limit set under the Criminal Code of Canada or the applicable motor vehicle;
during the voluntary leave portion of the maternity leave, as described under the definitions section, for a total disability occurring during this period;
during a parental or family-related leave, for a total disability occurring during this period.

Third-Party Claim

A member who has applied for weekly indemnity benefits under this Policy must notify the benefits provider in writing as soon as reasonably practicable of the full particulars of any third-party claim.

The member shall provide the benefits provider progress reports on the status of the third-party claim from time to time upon the request of the benefits provider.

As soon as a member is reasonably able to do so, the member shall provide the benefits provider in writing with full particulars of the net proceeds of the third-party claim supported by copies of any judgment, settlement agreement, release, correspondence including correspondence between the member and their own solicitor, fee agreements between the member and their own solicitor and such further and other documentation and information as the benefits provider may reasonably require.

A member shall, upon the request of the benefits provider, provide the benefits provider with the member’s written consent, direction and authorization as may reasonably be required to permit the benefits provider to obtain copies of any documentation or information relative to a member’s third-party claim from the member’s own solicitor, the Insurance Corporation of British Columbia (ICBC) or such other person, agency or entity as may be in possession or control of any documentation or information relevant to the member’s third-party claim.

Upon payment of a member’s net proceeds of a third-party claim, the member shall forthwith pay to the benefits provider the lesser of the aggregate of all prior weekly indemnity benefit payments in respect of the subject total disability paid to the member under the weekly indemnity benefit and the net proceeds of third-party claim. Should the member fail to repay this sum as and when recovered, the amount shall be recoverable by the benefits provider from the member in debt and should the benefits provider commence legal proceedings in respect thereof, the member shall also be required to pay all reasonable and proper legal fees incurred by the benefits provider in respect of such legal proceedings on a solicitor and own client or full indemnity basis. The amount the member is required to reimburse shall be determined with reference to the dollar amount of the net proceeds of the third-party claim and shall not be reduced by reason of the member or others being partially responsible for the damages arising from the events or circumstances causing the total disability.

In the event that a member’s net proceeds of third-party claim exceeds the aggregate amount of weekly indemnity benefits paid to the member, if then still totally disabled, shall not be entitled to any further weekly indemnity benefit payments under this policy unless and until a sufficient period of time thereafter has elapsed during which the member, but for this provision, would have received weekly indemnity benefits (including any enhancements implemented during that period) totalling in the aggregate to an amount equal to the amount by which the member’s net proceeds of third-party claim exceeded the amount paid to the benefits provider.

If required by the benefits provider, the member shall enter a reimbursement agreement containing the member’s express agreement to observe and perform the member’s obligations under this provision and providing for an assignment by the member to the benefits provider of the member’s net proceeds of third-party claim as security for the performance of the member’s said obligations.

Termination of Benefits

Weekly indemnity benefits payable under this benefit will cease on the earliest of:

the date on which the member ceases to be totally disabled
the date on which the member engages in any gainful occupation other than an approved gainful occupation for rehabilitation
the date on which the member fails to provide satisfactory proof of continued total disability to the benefits provider
the date on which payments have been paid, up to the maximum benefit period for any period of total disability
the date on which the member refuses to participate in a disability management program or to take up rehabilitative employment considered appropriate by the benefits provider; and
the date on which the member attains the termination age under this benefit.

However, if a member is totally disabled prior to this termination age and on attaining it, they are still totally disabled and have not yet received 15 weeks of benefit payments for that disability, notwithstanding the termination age of this benefit, coverage will be extended to the earliest of:

the date such member has received 15 weeks of benefits
the date such member ceases to be totally disabled; or
the date such member retires.

Extension of Benefit After Termination

If a member is totally disabled on the date his insurance terminates, the benefits provider will continue insurance for that total disability as if the insurance under this benefit for that member were still in force, provided such total disability continues uninterrupted, and premiums continue to be remitted.

Notice and Proof of Claim

Written proof of a claim must be submitted to the benefits provider within 60 days of the date total disability began. You must submit subsequent written proof satisfactory to the benefits provider of continued total disability when requested.

Disclaimer:

The information contained on this website is provided for general information purposes only. Every effort has been made to ensure that this information is accurate, but this site is not a substitute for the official Plan documents, nor is it an employment contract. In the event there is a discrepancy between this website and the official Plan documents, the official Plan documents will prevail. For more information, or if you have questions about the information provided on this website please contact your School District Benefits Administrator.