Q. How do I know what exactly I am covered for?

A. Your Employee Benefits Booklet outlines the coverage provided by your group plan. If you don’t have a Employee Benefits Booklet please ask your employer’s Group Plan Administrator for a current copy. Your Plan Administrator can also answer any additional questions you may have. You should occasionally review your Employee Benefits Booklet and your own coverage under the group plan, to ensure that all information on record is accurate.

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Q. What paramedical benefits require a doctor’s referral in advance?

A. If your claim is for registered massage therapy, most plans require a doctor’s written referral to be sent in with the claim. Otherwise, most plans do not require a doctor’s referral for services rendered by a chiropractor, naturopath, osteopath, podiatrist, chiropodist, clinical psychologist, licensed physiotherapist, speech therapist or acupuncturist. However, there are exceptions to these situations and you should review your Employee Benefits Booklet first for coverage and any claim requirements specific to your plan.

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Q. What if my claim will exceed $500?

A. RWAM suggests that you obtain a detailed treatment plan from your provider and submit it to RWAM prior to starting any treatment that is expected to exceed $500. We will then advise you of the amount for which you are eligible to be reimbursed.

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Q. My spouse has benefits through his/her employer. I’m covered under his/her plan and he/she is covered under my plan. To which plan should I submit claims?

A. This is called Coordination of Benefits (COB). Payment of an eligible benefit is coordinated between your plan and your spouse’s plan so the total coverage amount available doesn’t exceed 100% of allowable expenses. You should submit your claim to your own insurer first. Claims for dependent children must be submitted to the plan of the parent with the earlier birth date in the calendar year. If the parents have the same birth date, then submit the claim to the plan of the parent whose first name begins with the earlier letter in the alphabet.

In situations where parents are separated / divorced, then the following order applies: 1) the plan of the parent with custody of the child; 2) the plan of the spouse of the parent with custody of the child; 3) the plan of the parent not having custody of the child; and 4) the plan of the spouse to the parent in item (3). Take photocopies of your claim and receipts. Submit your claim to your insurer based on the above criteria. Once you receive your cheque and Explanation of Benefits (EOB) statement, complete a new claim form for the other carrier. Attach the EOB statement with photocopies of your original claim. Submit this information to the coordinating plan (your spouse’s). If you have any questions, please call our Claims Department.

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Q. Can I fax or e-mail my Health or Dental claim to RWAM for payment instead of mailing it in?

A. No. RWAM requires the original signed claim form and original receipts to process your claim.

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Q. How long does it take to process my claim?

A. RWAM’s goal is to process standard Health and Dental claims within 5 business days. If information is missing, or if additional information is required for more complex claims this will delay processing and the claim may have to be returned to you. If all required information is provided, your cheque should be mailed within 2 business days after processing. You can reduce waiting time by signing up for Electronic Deposit of Group Benefit Payments and your reimbursement will be electronically deposited to your bank account. Click here to obtain an ‘Application for Electronic Deposit of Group Benefit Payments’ form.

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Q. Can I have my claim payments deposited directly to my bank account?

A. Yes. Approved Extended Health Care, Dental, and Short Term Disability claim payments can be deposited directly to your bank account. You also have the option to have your Explanation of Benefits (EOB) statement either sent electronically to your personal e-mail address or sent by mail to your home address. Contact your Group Plan Administrator or RWAM Group Administration, or click here to obtain an ‘Application for Electronic Deposit of Group Benefit Payments’ form and submit it to RWAM. A void cheque must be returned with the completed form. Please remember to notify RWAM in writing of any change to your banking information, or to your home or e-mail address.

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Q. Why don’t I get my receipts returned after my claim has been paid?

A. The Explanation of Benefits (EOB) statement you receive after submitting a claim acts as your official receipt and provides all the information you may need for both tax and Coordination of Benefit (COB) purposes. It contains information on any deductibles, maximums, or co-payments applicable to your claim. You would use the EOB statement to submit COB claims to your spouse’s plan. It is advisable to retain copies of your EOBs for income tax purposes and COB purposes. You may wish to make a copy of your receipts before you submit them to your insurer.

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Q. I understand charges and amounts covered for dental work I have had done are based on a fee guide. What is a fee guide?

A. Dental fee guides are established and published by provincial dental associations - for example the Ontario Dental Association. Fee guides serve as a reference for dental practitioners to develop fee structures that are fair and reasonable for the patient and the practitioner. Insurers use these guides to provide consistent benefits within provinces and in the management of their dental plans.

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Q. What should I do if I experience a medical emergency while out of Canada or my province of residence?

A. If your plan includes the Out-of-Province/Out-of-Canada Travel Assist benefit, it is important to contact Travel Assist as soon as the medical emergency arises. In Canada & the USA call 1-866-520-8829. Anywhere else in the world call collect 519-742-4196. These phone numbers are printed on the back of your RWAM OneCard (if your plan includes this benefit) and on the Travel Assist brochure. Advise that you are insured through RWAM and quote your RWAM certificate number. Explain the medical emergency and the help you require. Travel Assist will direct you to the closest, most appropriate medical facility. Travel Assist brochures are available here for you to download.

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Q. Who is eligible for Group Insurance coverage?

A. To be deemed eligible, an employee must:

• Be actively working,
• Be employed by your company on a permanent basis,
• Work the required minimum number of hours per week on a regular basis (as specified in the Employee Benefits Booklet),
• Complete the waiting period (as specified in the Employee Benefits Booklet),
• Belong to a division and class of employees eligible for your plan,
• Be insured under a provincial government health plan and reside in Canada.

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Q. What does Non-Evidence Maximum (NEM) refer to?

A. Certain benefits (such as Life, AD&D and Disability coverage) may be wage-related. A Non-Evidence Maximum (NEM) refers to the maximum amount of insurance coverage which may be available to an eligible insured person without having to provide medical evidence of health (Evidence of Insurability). If a NEM applies to a particular benefit under your group plan, the NEM amount will be stated in your Employee Benefits Booklet on the applicable ‘Schedule of Benefits’ page. For some group plan benefits without a specified NEM, mandatory Evidence of Insurability may need to be provided. Check with your Group Plan Administrator.

You should review your coverage regularly, especially if your salary increases, to determine if you are eligible to apply for additional coverage beyond the NEM (sometimes called ‘excess coverage’). Coverage approved over and above the NEM will be subject to an overall maximum coverage amount, stated on the ‘Schedule of Benefits’ page of your Employee Benefits Booklet as the maximum coverage amount available with approved Evidence of Insurability. If you are uncertain or have any questions about your eligibility, contact your Group Plan Administrator or RWAM Group Administration.

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Q. Assuming I’m eligible to do so, how do I apply for coverage above the NEM (Additional Coverage)?

A. You must complete and submit a Group Health Evidence form (also known as an Evidence of Insurability form) to RWAM to apply for consideration of your eligibility for excess coverage over and above the NEM. Please ensure that the correct insurance provider’s form is submitted (providers are listed at the back of your Employee Benefits Booklet). Health evidence forms for the various insurance providers are available here. Additional coverage will only become effective once the insurer approves coverage after reviewing your health evidence. If your application for the desired excess coverage is declined you continue to be eligible for any existing coverage you already hold.

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Q. Can I have my claim payments deposited directly to my bank account?

A. Yes. Approved Extended Health Care, Dental, and Short Term Disability claim payments can be deposited directly to your bank account. You also have the option to have your Explanation of Benefits (EOB) statement either sent electronically to your personal e-mail address or sent by mail to your home address. Contact your Group Plan Administrator or RWAM Group Administration, or click here to obtain an ‘Application for Electronic Deposit of Group Benefit Payments’ form and submit it to RWAM. A void cheque must be returned with the completed form. Please remember to notify RWAM in writing of any change to your banking information, or to your home or e-mail address.

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Q. Do I need to report changes in my personal status?

A. Yes. You should contact either your Group Plan Administrator or RWAM Group Administration directly to report any changes in your personal status or life circumstances which might affect your coverage, including:

• Marital status (divorce, marriage, separation, common-law)
• Changes in your name or that of your dependent(s)
• Birth of a child, adoption, student coverage, disabled child

Whenever you have a major life change, it is advisable for you to review your beneficiary designation to see if it is up to date and reflects your current wishes. Refer to your Employee Benefits Booklet for more information under the heading "Changes Affecting Your Coverage".

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Q. Can I cover my spouse and dependent children?

A. Generally, yes. If your plan has Extended Health or Dental benefits, you need to choose family coverage for your eligible dependent(s) to be covered. Your Employee Benefits Booklet contains detailed information as to spousal and dependent child eligibility requirements. Most plans allow for an extension of coverage for a dependent child over age 21 who qualifies as a full-time student. If you have a dependent child with a mental or physical disability, or any other special circumstances, please contact your employer’s Group Plan Administrator or RWAM Group Administration to determine if coverage is available or can be extended.

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Q. I’m leaving the company and will no longer have any group Life, Health and Dental insurance. What options are available for me?

A. If your Group Life insurance coverage is being terminated because your employment has terminated or you are no longer eligible for group coverage, you may be entitled to convert your existing Group Life coverage to an Individual Life insurance policy. To convert group life coverage to an individual policy, you must apply to the insurer (via RWAM) within 31 days after the date your group coverage terminates. You should contact RWAM’s Group Life Insurance Department immediately for information and necessary forms.

Health and Dental - Depending on your plan design, you may be eligible to convert your group coverage to an individual plan. This must be done within 60 days of losing your group coverage. Please contact RWAM’s Group Life Insurance Department for further information.

For Out-of-Canada/Out-of-Province options, please call TIC Travel Insurance at 1-888-737-2228 and quote Agent Code 8142.

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Q. Do I qualify for Short Term Disability (STD) or Long Term Disability (LTD) benefits?

A. To qualify for WI or LTD benefits, you must be an eligible insured employee, meet the definition of total disability under your group insurance plan, complete the applicable elimination period (specified in your Employee Benefits Booklet), and otherwise satisfy the terms of your group disability plan. Your application for disability benefits will be assessed by the insurer, who will advise you of the decision on your claim.

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Q. How do I apply for Short Term Disability (STD) benefits?

A. Immediately upon your ceasing work due to illness, hospitalization or accident, an ‘Application for Group Short Term Disability Benefits’ form should be obtained from your employer or RWAM Disability Management. There are three sections to this form. 1) The Employer Statement must be completed by your employer. 2) The Employee Statement must be completed by yourself. 3) The Attending Physician’s Statement must be completed by your licensed physician.

Ensure that all three sections of this form are fully completed, and include any additional medical information (e.g. copies of test results, specialists’ reports, doctors’ notes). Then submit all documents directly to RWAM Disability Management for assessment of your claim.

If approved, your WI benefits are paid bi-weekly. Benefit payments are mailed confidentially to your attention via your employer’s office. If you prefer, they can be mailed to your home address, or you can arrange for direct deposit to your designated personal bank account.

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Q. If I am receiving Short Term Disability (STD) benefits, will my WI premiums be waived?

A. WI premiums are only waived when an employee is eligible and in receipt of LTD benefits.

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Q. How do I apply for Long Term Disability (LTD) benefits?

A. First determine the elimination period that must be satisfied before you are eligible to apply for benefits - this information is in your Employee Benefits Booklet. Approximately six to eight weeks before the end of your elimination period, obtain an ‘Application for Group Long Term Disability Benefits’ form from RWAM Disability Management or your employer’s Plan Administrator. There are three sections to this form. 1) The Employer Statement must be completed by your employer. 2) The Employee Statement must be completed by yourself. 3) The Attending Physician’s Statement must be completed by your licensed physician. Ensure that all three sections of this LTD application form are fully completed, and include any additional medical information (e.g. copies of test results, specialists’ reports, doctors’ notes).

Submit all documents directly to RWAM Disability Management (RDM). Most LTD claims are adjudicated and paid directly by the insurer, and not by RDM. RDM forwards your claim to the insurer by courier, together with any coverage or eligibility records held by RWAM and required by the insurer. Once your claim is submitted, RDM can refer you to the appropriate parties at the insurance company.

If approved, your LTD benefits are paid monthly. Benefit payments are mailed confidentially to your attention via your employer’s office, or you can arrange to have them mailed to your home address. Depending on the insurer, it may be possible to arrange for your benefit payments to be direct deposited to your designated personal bank account.

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Q. What can I do to avoid delays in the assessment of my disability claim?

A. Follow these guidelines to avoid delays in the assessment of your disability claim:

• Make sure all forms are fully completed and signed.
• Provide details of all additional home and work-related factors affecting your ability to be at work.
• Ask your employer to provide both your physician and the insurer with your most recent job description and task analysis on each job function.
• Ask your doctor to include reports from all specialists, results of all testing, and any other medical information. If any information provided is insufficient or not clear, the insurer may need to write to your physician for more information, resulting in a delay of your claim.
• Provide copies of any WCB/WSIB, Employment Insurance, CPP/QPP, auto insurance and any other benefit claim records, if you have applied for, or are receiving benefits from these other sources.
• If you are age 60 or over, you must submit proof of age with your application.

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Q. What is your Early Intervention program about?

A. If your group’s LTD plan includes this service, and if appropriate, RWAM Disability Management (RDM) offers an Early Intervention Program to eligible employees claiming LTD benefits. It is designed to assist you and improve opportunities for the earliest possible safe return to work. For example, RDM can arrange a work trial, with modification of assigned duties and/or hours; or we can make other recommendations. By being involved early on in your rehabilitation, RDM can assist you with gathering medical information that you may need to submit your LTD claim to the insurer, provide information and monitor your progress.

If you have been absent from work due to disability for 10 calendar days, and wish to take advantage of the Early Intervention program, you or your employer should notify RWAM Disability Management of your absence. We will then arrange for Early Intervention forms to be sent to you.

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Q. What if I have applied for Workers Compensation (WSIB/WCB) benefits?

A. You must still submit a completed disability claim application form and any other supporting documents to RWAM Disability Management within the time periods required by your group plan, even if you have applied or intend to apply for WCB/WSIB. Please include a copy of your WSIB/WCB claim records. By doing this, your group benefits claim is not compromised should your WSIB/WCB benefits be denied or discontinued.

Most group disability plans require the LTD benefit amount to be directly reduced by the WSIB/WCB payment amount. Even though this may happen, if your LTD claim is approved, charges for your LTD premium (and sometimes your Life & AD&D premiums) may be waived while you are approved by the insurer for LTD benefits. If you qualify for WCB/WSIB benefits after your group disability claim has been approved, or your WCB/WSIB benefit amount changes or discontinues, you must notify RWAM Disability Management immediately in order for your claim to be re-assessed. In the event the insurer has overpaid you while you were also receiving (or granted retroactively) WCB/WSIB for the same time period, you will be required to refund the insurer.

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Q. How do I know if my benefit is taxable or non-taxable? Will I receive a tax slip?

A. If your employer pays all or part of your WI or LTD insurance premium, any disability benefits you receive will be taxable. The applicable Schedule of Benefits in your Employee Benefits Booklet indicates whether your WI or LTD benefit is taxable or non-taxable. However premium contribution information could change without RWAM’s knowledge so if you have any questions, please check with your Plan Administrator.

If your benefit is taxable, a ‘T4A’ slip will be issued by the insurer (usually by the end of February) stating the amount of disability income paid to you in the previous year. You are required to claim this income on your income tax return. Some disability plans automatically deduct income tax from your taxable benefit at source. If your plan does not do so, most insurers will arrange to do so at your request.

If your disability benefit is non-taxable, you will not receive a tax slip and no statement is issued.

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Q. Are rehabilitation services available to assist me?

A. RWAM Disability Management (RDM) offers a professional team of rehabilitation personnel with training and experience in fields such as ergonomics, kinesiology, psychology, occupational therapy, and nursing.

With the insurer’s approval and subject to your disability plan’s design, RDM’s rehabilitation staff will work with your employer, your doctor and other health care practitioners involved in your care, to assist you in taking measures to help expedite your recovery and to facilitate an appropriate, safe and sustainable return to work plan. Where possible, rehabilitation staff can assist with your treatment plan. Vocational assistance, if appropriate, may also be available.

Once your claim is approved, a RDM rehabilitation case manager may contact you to discuss your progress and a return to work plan.

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Q. Why would my disability claim be denied?

A. Your claim will be denied if you are not eligible for group disability coverage, if it is determined that the medical evidence does not support that you are totally disabled, or if you do not otherwise qualify for disability benefits under the specific terms of your group disability plan. A diagnosed medical condition is not necessarily a disabling medical condition when applied to the definition of Total Disability under your specific group insurance plan.

For certain medical conditions, research shows that it is possible and may be more beneficial for a person to remain at work while being in active treatment, and that this approach may shorten the recovery period. Benefits will not be approved for time taken off work due to work-place issues, which may include difficult relationships with co-workers, increased workloads and job demands. Actions taken by employers in good faith such as discipline, work evaluation, transfer, lay-off, demotion or termination are generally regarded as a normal part of the work situation and not as a basis for "total disability" (i.e. unable to work due to illness or injury).

If your claim is denied, the insurer will send you a confidential letter outlining the
reason(s) for the decision.

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Q. Should I apply for Canada Pension Plan (CPP) / Quebec Pension Plan (QPP) disability benefits?

A. Not necessarily, especially if you are expected to recover and return to work. Generally you would qualify for CPP/QPP only if your disability is considered by the government to be ‘severe and prolonged’. Check the government website at www.servicecanada.gc.ca for more information.

Your LTD claim is assessed independently of CPP/QPP eligibility requirements. However under most LTD group plan designs, the insurer has the right to require you to apply for CPP/QPP disability benefits if the insurer believes you may be eligible, and your LTD benefit is adjusted for the amount of CPP/QPP granted. Should you be granted CPP/QPP at any time, you should send a copy of your Notice of Entitlement to RWAM Disability Management to be passed on to the LTD insurer. If your claim for CPP/QPP is denied, the insurer may ask you to appeal that decision or to reapply.

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Q. I have family coverage. Does my Disability coverage apply to my spouse as well?

A. No. Generally speaking the term “family” coverage in group insurance applies only to any Extended Health, Dental or Out-of-Province/Out-of Canada coverage you might hold under your group benefits plan. Additional benefits, like Disability, you may hold under your group benefits plan are strictly to provide benefits for you the insured employee and are not extended to cover your spouse or your dependent children even when you have selected family coverage.

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Q. What about confidentiality and privacy?

A. You are not obligated to share confidential medical information with your employer. When submitting a claim, you may submit the completed Employee Statement and Attending Physician Statement sections of your disability application form directly to RWAM Disability Management.

RWAM does not release confidential medical information to your employer. However, your employer is entitled to know that you have claimed disability benefits, along with certain basic information such as the status of your claim, your ability to perform your own occupation and any limitations or restrictions your employer needs to know in order to properly accommodate your return to work and provide appropriate modified duties if needed.

RWAM is committed to protecting the privacy, confidentiality, accuracy and security of the personal information that it collects, uses, retains and discloses in the necessary course of conducting its business. For further information regarding RWAM’s privacy policies, please refer to your Employee Benefits Booklet, ask for a copy of RWAM’s Privacy brochure, or read the Privacy Policy posted on our website.

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