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How Do I

How to File a Claim for Weekly Wage Replacement Benefits

Claim forms are available from the Claim Office of Benefit Plan Administrators Limited. If you are claiming for Wage Replacement a specific form must be used. This form consists of the following sections:

  • Attending Physician's Statement
  • Member Statement of Claim
  • Employer Section

Your Physician must complete the "Attending Physician's Statement" portion of the form. Make sure your Physician clearly indicates the diagnosis, date(s) of service and type(s) of service rendered, and an estimated return to work date. Your Physician must complete the form after you stop working. Forms completed in anticipation of medical treatments are not acceptable.

Remember! You must be under the continuous personal care of a Physician to qualify for Wage Replacement benefits.

You and your employer must also complete your sections of the form before it is returned to the Claims Office. To avoid delay in payment, please make certain that all required information has been provided. Once the claim has been approved your benefit cheque will be mailed directly to you.

It is important to note that you will be required to regularly provide medical evidence from your attending Physician. This medical evidence must be sufficient to establish and maintain your inability to perform the usual functions of your job. You must be under the continuous care of a medical Physician for the full 106 week period, which includes the waiting period and any period during which you received E.I. benefits; and your treatment must be appropriate to the diagnosis indicated. Alternative or experimental treatments are not recognized by this plan.

Remember! Your benefits will be reduced by CPP/QPP Disability benefits from the 27th week of disability. If you do not advise the Claims Office of the status of your CPP application, your benefits may be suspended until you do.

If it appears that you will continue to be disabled after 104 weeks of receiving wage replacement benefits, at approximately 98 weeks, the Administrative Agent will send you the appropriate forms for completion (with instructions), so that you may apply for benefits under the Long Term Disability benefit portion of the Plan.

Proof of Loss

Written proof stating the occurrence, character and extent of loss must be submitted to the OHI/HHI Disability Claims Office within 90 days after the termination of the period for which the Insurer is liable. Failure to provide such proof within the time required shall not invalidate nor reduce the claim if it was not reasonably possible to give proof within such time, provided such proof is furnished as soon as reasonably possible and in no event, except in the absence of legal capacity, later than one year from the time proof is otherwise required.

The Trust Fund shall have the right and opportunity to independently examine any person whose injury or illness is the basis of claim, when and as often as it may reasonably require during the pending and payment period, if any, of such claim.

How to File a Claim for Long Term Disability Benefits

After approximately 98 weeks of receiving combined Weekly Wage Replacement and Employment Insurance sickness benefits, the OHI/HHI Disability Claims Office will send you the appropriate forms for completion (with instructions), so that you may apply for benefits under the Long Term Disability benefit portion of the Plan.

When the forms have been fully completed by yourself, your employer and your Physician, forward the forms to the Claims Office. Your benefit cheques will be mailed directly to you.

Remember! You must be under the continuous personal care of a Physician to qualify for Weekly Disability Income and Long Term Disability benefits.

Proof of Loss

Written proof stating the occurrence, character and extent of loss must be submitted to the Administrative Agent within 6 months after the end of the qualifying period for Long Term Disability Insurance. The qualifying period is 106 weeks, therefore you must apply within 30 months of leaving work due to disability.

Written proof of the continuance of disability must be furnished to the Claims Office at such intervals as it may reasonably require. As part of the proof, the Claim Adjudicator shall have the right to require satisfactory evidence that the Member has made application for all benefits referred to in the reductions provision and that he has furnished all required proofs for such benefits. If the Member did not make such application, he must provide satisfactory evidence that he was not eligible for such benefits. The Claim Adjudicator shall also have the right to require satisfactory evidence of the amount of such benefits payable.

The Claim Adjudicator shall have the right and opportunity to independently examine any person whose injury or illness is the basis of claim, when and as often as it may reasonably require during the pending and payment period, if any, of such claim.

Insulators Local 95 Benefit Trust Fund c/o Benefit Plan Administrators 
90 Burnhamthorpe Road West, Suite 300 Mississauga, Ontario L5B 3C3