The ‘own occ to any occ gap’ is one of those vortex or black holes in claims management where employees drift off into never never land. Employers do not typically handle these well because they usually come as a surprise. I could say it’s a gift to the organization but it really isn’t. It’s a conundrum. What it is, is fairly easy to explain; but what to do with it, is the conundrum.
First before explaining the ‘any occ gap’, let me explain the ‘own occ’ clause.
The ‘own occ’ (own occupation) clause is when the employee has satisfied the first 2 years of the long term disability requirement as being unable to perform their own occupation for up to 2 years following the short term disability plan. The insurance carrier decides with multiple medical and functional reports that the employee is unable to perform the essential tasks of their own job, so they begin the long term disability plan that the employer/employee has purchased. The employee remains on these benefits for up to 2 years if they remain disabled from performing their own occupation.
Now comes the ‘any occ gap’. Just because the employee has gone 2 years on long term disability, it does not mean that they continue on these benefits. The disabled employee must re-qualify for the next stage of long term disability called the ‘any occ’ stage where the employee must NOT be able to perform any occupation (any occ) in order to be eligible for continued long term benefits.
The ‘own occ – any occ gap’ occurs when the employee has completed their short term disability benefits, qualified for 2 years of long term disability BUT does NOT qualify for continuing long term disability benefits, because they ARE capable of performing some type of occupation, just not their own. The conundrum comes right here: the insurance company denies further benefits past the 2 year mark, and the employee remains off work, unable to do their own job, without benefits or a job. You, the employer and your case manager NEED TO SEE this happening. Don’t wait until you get the notice from your long term insurance carrier. Have a plan for these situations before they occur.
So now you have an employee that has been away and unable to perform their own job, in most cases, 2 1/2 years, suddenly without benefits because they ARE capable of performing a job, just not their own. Many employees are not able to work at all according to the medical but the insurance carrier deems them able to work.
The conundrum comes as, ‘Now, what do you do with this employee who can’t do his own job, and according to his doctors any job? And what does the employee do if he can do a job, but not his own?’ This is when your next move as the employer becomes extremely complicated with many legal and human rights implications, if not done well.
My best recommendation if you are in this predicament, is the following:
1. Don’t find yourself there a second time ever, by learning from the first case.
2. Be prepared to manage this situation at least 6 months before the end of the employee’s LTD claim by being cognizant of the potential for this to occur.
3. Have a plan in place to address the employee’s potential accommodated return to work, retirement or other scenarios that will play out.
Lucie M.H. Fournier RN, COHN(C), BA (Psych)
Founder/Workplace Health Strategist
With over 30 years of experience in disability management, and a return on investment on average of 1:7, Fournier disAbility & Health provides customized and results oriented services in Absenteeism Management including Attendance, Sick Time/Short, Long Term Disability, and WSIB claims for employers across Ontario.
Expertise in 5 distinct niches of disAbility management include:
1. Complex claims management resolution
2. Mental health claim return to work & accommodations
3. Advanced level training for internal claims manager to make a significant impact on the health of the employee and wealth of the organization
4. Transitional Leadership when moving to & from a 3rd party disAbility Management company
5. Sensitive claims & disAbility management of professional staff, such as HR, health team, and/or executives such as supervisors, managers, directors
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