Validating Medical Claims: do you get true value for your contributions?

Anyone who’s employment situation offers them extended health is often under the mistaken notion that their policy will be triggered should a medical need arise. By in large, most people have no idea, nor does anyone take the time to explain to them, that there are expectations that are required in order to receive these benefits. 

A recent mediation highlighted this concept, sufficient that I felt obligated to share it with the readers. A Plaintiff we will call Susan, who had been gainfully employed for other 20 years, became injured and required treatment from her doctor. The nature of her injury was such that she was medically restricted from work, initially for 2 weeks. On receipt of this medical certificate from her doctor, she duly provided it to her employer. As is the case, she still was not fit for work at the end of two weeks, and her doctor chose to extend the medical leave for a further period of time. Given that she had been off for some time, the employer needed to trigger coverage through her short-term disability (STD), and provided her with a series of forms to be attended to by her doctor. In her next appointment with her doctor, she provided these forms and the doctor complied and filled them out. However, it appears the forms were not filled out to the satisfaction of the employer. Although this was communicated to Susan, her understanding was that her doctor had provided the requisite information. Based on this, she contacted her doctor’s office, who assured her the information was sent. Assuming that it was just lost in the mail, she continued on her medical leave, which was again extended. Unfortunately, her employer’s medical forms were time sensitive and given they had not been completed by her attending physician in a satisfactory manner she was deemed to have abandoned her employment. After the final due date for the forms, her employment was terminated based on the claim that she had abandoned her position, and substantiated by the comment that she had failed to provide the requisite medical documents. The result was that, from that day forward, the employer withheld any payments to her, including severance, based on the logic that she had not retired but rather quit. With no other recourse available, Susan was forced to sue them. In the end, out of desperation and financial need, Susan ended up accepting a small settlement in order to survive. 

Having reflected on this, it appears to me, based on some of the requests that come into our office, that this situation is more common than one would presume. In reality, if one is not a medical professional and they are provided with a medical certificate restricting them from work, the question becomes should they listen to their doctor and stay at home, or should they return to work in the event that their doctors certificate does not comply with the requisites of the insurance company providing their extended health benefits. In order to make this decision, we are imposing a constraint on the claimant to fully comprehend and understand what the requisites for disability are, and moreover, what a medical note/certificate should contain to comply. This is a cach-22 that people are caught in everyday. If they take the time off, they may be jeopardizing their job and source of income, potentially losing their employment. On the other hand, if they go to work and they do further damage to themselves they may be the author of their own misfortune and may still cause them to be eliminated from the insurance policies dictates. Unfortunately, for most people in this situation, they try to cope the best as possible without the benefit of an advocate who can guide them as to what is appropriate. Propositionally we suggest that this would be an ideal time for the companies HR department to reach out to them and ensure that they completely understand what is required of them, to work with them, and facilitate their doctor’s referral complying with the requisites of the insurance company. Unfortunately, most people do not have such an advocate, and therefore through no fault of their own, but rather through lack of knowledge, they easily fall through the cracks and for many later become unemployed, with no viable source of income.  

In an ideal situation, when a person becomes ill, visits their doctor and is restricted from work for either a mental or physical illness, they should be given a note to provide to their employer with a caveat that says, if the information provided is insufficient, could they kindly contact the doctor so that s/he can ensure compliance. Potentially, there is an option that would also permit the doctor to lay out their recovery plan such that, if the person is not better after the initial certificate, and needs a further extension of time, a further explanation could be given to the employer. In the event that they meet the criteria for short term disability (STD) from their employer, they could make that application at this stage. Alternatively, they could apply for EI, through the Government of Canada. In the event that they are not accepted for STD, depending on the nature of the illness, they can apply for long term disability (LTD) from the Canadian Pension Plan (CPP) assuming that they have not recovered in sufficient time such that either their EI runs out, or their STD becomes LTD. Alternatively, if they have been accepted, and the time has been so long that their STD now becomes LTD, this will provide them with a viable source of income or in the event of a rejection of their claim, they will be able to fall back on their CPP or Workplace Safety and Insurance Board (WSIB). All of this hinges on the employer providing them forms with sufficient directions such that they understand, and the doctor who fills them out also understanding what needs to be included. In addition to this there should be a fail stop mechanism that if the information is not sufficient, the employer will engage with the employee and the doctor through a 3 way mediated process to ensure that the requisites are clearly understood by all, thus ensuring that the employee qualifies for the benefits they are entitled to, and minimizing the possibility that when they are well they don’t have a job to go back to. 

Most of the time, no such process exists or is sadly lacking. Not only is the employee commonly lacking in knowledge of how to complete the forms, but every insurance company has its own requisites and what may be acceptable from the doctor from one company may not be for another. More importantly than both of these factors, is that often times the employer does not consider the impact and cost of retraining an employee. An employee with 20 years training who is very efficient at their job has a value that seems to be discounted. This person has a level of competence that provides dependability for the employer. To replace this person, one needs to factor in the costs of training, the costs of supervising, and the costs of ensuring their comprehension of what is expected of them within the context of the employment culture. Unfortunately, this is missed most frequently by the employer, and what happens is a polarization between the employer and employee. What gets missed is the fact that there is a bonified benefit that has already been paid for in the health insurance contributions the employers have been making for the employee over the years, and would cost nothing to have the employee access, as is their legitimate right to do if they are injured. More over, and often overlooked, is the fact that an employee who has benefited from the program is very likely to have a greater deal of loyalty, which often translates to their willingness to give more than is expected of them. Hence, this puts the employer in a very good position, having a satisfied work force with employees extoling how good the company functions, needless to say, leads to higher satisfaction amongst employees, long terms of employment, less turnover in the company, and therefore also reduces hiring and training costs.  

In part, most of these issues can be dealt with in the intake process once the person is hired and being on-boarded. It is worth the employer’s while to take the time to fully explain to the employee how the process works. Simply because, at a later stage, if there are issues resulting from medical certificates, the person has an idea of how to address it and what to be on the look out for. It must be remembered that one consideration of all of this is that every time a company is challenged with a lawsuit, it costs them money and time. Most of which can be avoided if they had a seamless process in which the claimant could access their legitimate benefits. Given that companies are paying substantial amounts of money to purchase these extended health benefits, one would wonder why it does not behoove the insurer to have an in-person seminar for new employees, especially given that not only is the employer spending money, but so is the extended health company. By in large, the process has been that the employee is handed a benefit booklet, usually 50-60 plus pages, there is sufficient case law that suggests people do not read one-page contracts fully, let alone a handbook the size of this. What makes even less sense is while it may be an expectation for a higher level employee to have the time and underlying comprehension to read this, it is our opinion that one cannot extend the same expectation to a factory worker working at just above minimum wage on an hourly basis who is caught up in the process of survival, needing to get as many hours as possible, including overtime if available, to cover their family bills. 

One of the reasons it is so important that the previously suggested course of action (ie the benefits package) be explained to all new employees being onboarded, is because some companies do not have an extended health plan but the employee may believe they do, some employers have only a short term disability with no long term, and others have only long term but no short term. To the average schooled person this can be confusing, let alone someone who has no experience in the area. It is said that to fail to prepare is to prepare to fail, and if the employer is failing to prepare the employee by way of futuristic potential expectations, by analogy, the employer is preparing to prepare itself for failure when a problem actually arises. The more informed the person is, the more likely they are to comply with the requests and requisites. Further, even in today’s time, for many people the doctor is still seen as an authority figure, and if their doctor tells them to be off of work, they tend of obey. Moreover, when they, to the best of their ability, advise the employer and due to lack of inappropriate documentation they may not fully understand that their claim is being rejected, often times they personalize this as a challenge to their integrity and a rejection of their level of illness. Despite the fact that this may not be an employer’s motivation, it still needs to be a big consideration, especially since perception is reality and the injured person perceives themselves and their claim to have not been accepted. This again brings us back to the underutilized of the Human Resources in the onboarding process. Even if the company did not have a HR department, this function can still be achieved by having the insurer provide in house training seminars. At the end of the day, it is not only the claimant who has been robbed in as much as they have been denied their legitimate benefits through no fault of their own, but also by similar thinking, so has the company given they have contributed towards this persons insurance for years, and this person is no longer able to access legitimate benefits because of paperwork that did not comply through no fault of the person. Further, the stigma of the company not being a good employer attaches to the company, not the insurer, and the attendant’s disgruntlement amongst its employees who will become knowledgeable of the claim and its consequences via colleague who was ill is duly placed on the employer. As such, it behooves the employer to advocate for a change in this system, especially since the cost to them is so much greater without a change.  

Relevant Resources:

Employment Insurance (EI): https://www.canada.ca/en/services/benefits/ei.html

Canadian Pension Plan Disability (CPP): https://www.canada.ca/en/services/benefits/publicpensions/cpp/cpp-disability-benefit.html

Workplace Safety and Insurance Board (WSIB): https://www.wsib.ca/en

                       

Bruce Ally

Bruce Ally is the founder of A Place for Mediation. As a mediator in private practice he has conducted in excess of 4000 matters. He is an instructor in the Lawyer in Negotiation course at Osgood Hall Law School, and a facilitator in the Advanced Mediator Program and the Workplace… MORE >

                       

KESHIA OSBOURNE

Keshia Osbourne works as an associate at A Place for Mediation. She is certified by the Workplace Fairness Institute (WFI) as a Workplace Fairness Analyst and is on the WFI roster. MORE >