Long Term Disability Benefits

Long Term Disability (LTD) plans are designed to provide a monthly income to those employees confronted with loss of income during a lengthy or permanent disability. The amount of benefit and the benefit period are shown in the Schedule of Benefits.

Total Disability

To be eligible for this benefit, you must be under the continuous care of a physician. Blue Cross defines total disability as:

1. The complete and continuous inability to perform the regular duties of your own occupation as a result of illness or injury during the elimination period and for the following 60 months; and
2. Thereafter, total disability means a state of continuous incapacity, resulting from illness or injury which wholly prevents you from performing the regular duties of any occupation for which you:
   1. would earn 60% or more of your pre-disability earnings; and
   2. are reasonably qualified, or may so become by training, education or experience.

Regular duties are defined as those work related activities which are considered essential to the performance of your occupation and which proportionately take the majority of time to complete.

The availability of such occupations, jobs or work will not be considered while assessing your disability.

The loss of a professional or occupational license or certification does not, in itself, constitute disability.

Pension Benefit

Employees who contribute to the employee’s pension fund are entitled to the additional benefit amount shown in the Schedule of Benefits.

Survivor Benefit

If a totally disabled employee dies while in receipt of Long Term Disability benefits, the Company will pay to the designated beneficiary assigned under this policy a lump sum shown in the Schedule of Benefits.

Partial Disability

To be considered partially disabled, you must be deemed totally disabled throughout the elimination period shown in the Schedule of Benefits. If, following the elimination period, you are only capable of returning to the workforce in a reduced capacity, Blue Cross will apply the regular provisions under the Long Term

Recurrent Disability

Successive periods of total disability occurring while this coverage is in force will be considered to be one period of total disability as long as you become totally disabled from the same or related causes for which your claim for Long Term Disability was previously approved by Blue Cross and the intervals of total disability have not been separated by a period longer than six months.

If you return to work for a new employer and you are without disability coverage, you may be eligible to claim under this provision as long as your employment with the new employer is part of a return to work program that has been pre-approved by Blue Cross. Your claim for disability benefits cannot be approved under any other plan and you must become totally disabled from the same or related causes within six months of returning to active employment.

Elimination Period

The benefit elimination period, shown in the Schedule of Benefits, is the period of time which you must wait from the onset of the disability before the insurer begins paying Long Term Disability benefits.

When the disability is not continuous, the days you are disabled may be accumulated to satisfy the elimination period, provided coverage remains in force during the accumulation of the elimination period; no interruption is longer than 30 days; disabilities are due to the same or related causes and each period of total disability is completed within 365 days after the start of the elimination period, or as pre-approved by Blue Cross if longer.

Pre-Existing Conditions

Disabilities commencing within 12 months after your effective date, and for which you have received medical treatment, consultation, care or services (including diagnostic measures) or have been prescribed medication during the three months immediately prior to your effective date of coverage are not covered.

The pre-existing condition clause will not apply if you have been treatment free for any six consecutive months within the 15 month time period beginning three months before and ending 12 months after your effective date of Long Term Disability coverage.

Integration of Benefits

Monthly benefits are coordinated with income payments to which you become entitled as a result of your current disability. The benefit coordination is applied as follows:

Direct Offset Plan

1. The amount of monthly income from the Long Term Disability plan is reduced directly by any disability benefits available under the Canada/Quebec Pension Plan (primary benefits only), the Workers’ Compensation Act and “income from all other sources”. “Income from all other sources” includes:
   • disability benefits available under any other government program,
   • retirement benefits provided by any employer or government program,
   • income or benefits payable under any group program provided by or through your employer,
   • income or benefits payable under a plan sponsored by an association, union or fraternal organization of which you are a member,
   • income replacement benefits payable under any plan of automobile insurance, where such reduction is not prohibited by law, and
   • wages or remuneration payable from any employer or from self-employment but excluding 50% of earnings received under an approved rehabilitation program as defined below. (For nontaxable plans earnings shall mean gross earnings minus income tax. For taxable plans earnings shall mean gross earnings.)
2. The amount determined in A. above is further reduced if necessary, so that the amount of monthly income, including all amounts of income mentioned in A. above does not exceed 85% of gross earnings on taxable plans, or 85% of net earnings on nontaxable plans, except as provided under a rehabilitation
   program.

During the period of an approved rehabilitation program, the amount of monthly income as defined above, will be further reduced if necessary, so that the amount of monthly income together with all amounts of income in A. above, including 100% of earnings received from a rehabilitation program, does not exceed 100% of gross earnings on taxable plans, or 100% of net earnings on nontaxable plans.

Canada/Quebec Pension Plan Freeze

Once the initial Canada/Quebec Pension Plan offset has been established on a Long Term Disability claim, it will not be changed due to cost-of-living adjustments to the Canada/Quebec Pension Plan payments.

Exclusions and Limitations

Long Term Disability benefits will not be payable if disability, illness, injury or accident occurs while participating in or while engaged in any criminal activity, regardless of whether charges are laid or a conviction obtained.

Long Term Disability benefits are also not payable for any of the following:

1. any period of disability during which you are not under appropriate treatment and care of a physician who is a registered medical specialist or health care practitioner in the field of medicine which is applicable to your condition, or
2. any period during which you are not undergoing a course of medical treatment or participating in a program of rehabilitation which is deemed appropriate in the opinion of Blue Cross, or
3. any period during which you are imprisoned, or
4. any disability due to or resulting from self-inflicted injury or sickness, while sane or insane, or
5. any disability due to or resulting from insurrection, war (declared or not), or the hostile actions of the armed forces of any country, or the participation in any riot or civil commotion, or
6. any disability during the period:
   • of formal maternity leave taken by you pursuant to provincial or federal law, or pursuant to mutual agreement between you and your employer, or
   • in which employment insurance maternity benefits are being paid or would be paid if you were eligible, whichever is longer, or
7. any period during which you are absent from Canada due to any reason, unless Blue Cross agrees in writing in advance to pay benefits during the period.

Waiver of Premium

Any premium due under this benefit while you are totally disabled and qualify for Long Term Disability benefits, will be waived commencing with the first full calendar month following the end of the elimination period. Premiums will be waived until you return to active permanent employment or no longer qualify for benefits.