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Episodic Disabilities and Insurance: Action Items for Consumers

Are you a person living with HIV, MS, Arthritis, or another health condition that causes you to experience episodic disability (disability that comes and goes)? Are you eligible through your employer for health benefits and Short-Term (STD) or Long-Term Disability (LTD) Insurance?  These benefits can assist you in managing your health, but they can also be challenging to access for people with recurring and unpredictable conditions.  Here are some helpful suggestions.

Find out what is in your health benefits and STD and/or LTD plans.

Many people don’t find out what is in their plan until they need to access it. Be proactive and ask for a copy of your plan ahead of time, so you’ll be prepared and knowledgeable when you need it.

Engage with your available supports.

If you need more information or advice, ask for help from Human Resources or a similar administrative office. If you are unionized, your union representative is a good place to start with any questions you may have related to health benefits or insurance coverage.

Take a preventative approach.

Some of the things in your plan can help prevent episodes – find out what you are entitled to and use it to help you manage your episodic disability. For example, some health benefit plans allow for visits to massage therapists or mental health specialists. If you are entitled to these benefits and they would be helpful for you in managing your condition, access them.  Note, some of these services require a referral from your physician.

Provide feedback to your employer on the usefulness of the plan.

There are some insurance plan elements that can be particularly helpful for people living with episodic disabilities, as they make it easier to transition on and off claim. If you find that you are frequently moving on and off claim, you may want to talk to your employer to see if any of the following could be added to your plan:

A Recurrent Claims Clause

A recurrent claims clause allows for an individual to qualify for STD or LTD based on a reoccurrence of an established and qualified disability taking place within a specified period of time. Recurrent claims clauses are useful in that the new episode is treated as the same as the last episode and the individual is not then required to submit a new claim. There are usually time limits on these clauses; some limit the recurrence period to 6 months.

A Waiver of Elimination Period

In offering LTD, it is possible to request a Waiver of the Elimination Period. This essentially allows for an individual with a recurrent disability to qualify for support during an episode without the requirement of fulfilling a new waiting or elimination period. There are reports of elimination periods that extend for up to 5 years allowing for individuals experiencing recurrent periods of disability to immediately qualify for claim.

Remember, being prepared is an important part of self-advocacy. For more information on episodic disabilities please visit the Realize website.

Disclaimer: This fact sheet is provided for information only. Please consult with your insurance provider directly for details relevant to your unique circumstances.

Episodic Disabilities and Insurance: Action Items for Insurers

Are you a private health insurance provider encountering challenges related to supporting employees living and working with unpredictable and recurring episodic disabilities? Would you like to improve the affordability and efficacy of your services to this key population? Read on for action items you can take to improve services for this growing demographic:

• Conduct internal actuarial analyses to answer the question “Are there more efficient ways to manage episodes of illness for employees living with episodic disabilities?”
• Consider whether a specific “episodic disability leave” option that does not use the same criteria as short-term disability (STD) or long-term disability (LTD) is possible.
• For example, could someone living and working with an episodic disability have access to 6 months of intermittent time during a period of 24 months, which would count as STD and then any time after would be treated as LTD? This would eliminate the administrative costs of opening and closing cases per episode and would activate At Work Services more quickly for employees who can stay at work during their episode.
• Is there a different definition for “disability” that would work better when there are unpredictable periods of illness and wellness?
• Is there a different definition for “return to work” that would make more sense for employees whose capacity can fluctuate from day to day or week to week depending on their symptoms?
• In evaluating whether someone is totally disabled from the workplace, can the focus be on capacity as opposed to disability?
• Engage your clients to develop more appropriate administrative processes from the perspective of employers and HR departments.
• In order to get a better idea of the impact that STD/LTD leaves on the organization, encourage employers to implement business line reporting when implementing a STD/LTD program. This will assist in clarifying what associated costs may be.
• For small businesses that cannot afford full STD/LTD programs, offer “At Work Services” that assist vulnerable employees who are living through an episode to stay at work or offer “Advice to Pay Services” that can be activated as needed when an episode becomes too difficult to manage at work.

For more information on episodic disabilities please visit the Realize website.

Disclaimer: This Fact Sheet is provided for information purposes only.

Copyright Realize 2017                        

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