If you are eligible for long term disability benefits in Ontario, it is important to understand how disability is defined in your policy. In general, there are two tests that insurers use to determine whether you are considered disabled and qualify for benefits. The own occupation disability test means you are considered disabled if you are too injured or ill to perform the duties of your own job. The any occupation disability test applies if you cannot work in any job for which you are reasonably qualified.
The difference between own occupation and any occupation definitions can significantly affect how your LTD claim is assessed. If you have already been denied LTD benefits or if your insurer is saying that you no longer qualify, you can contact my law firm, Derek Wilson Injury and Disability Law, for a free consultation.
What Is the Difference Between Own-Occupation and Any-Occupation in Ontario?
Under the own occupation test, you are considered disabled if your condition prevents you from performing the essential duties of the job you had when you became disabled. Even if you can perform some minor or optional tasks, you are considered disabled if you cannot carry out the core duties of your work. You may still be eligible for benefits even if you could perform other roles or household tasks.
Any occupation means you cannot perform the core duties of any suitable job. After a set period, usually about two years, most policies switch to this stricter definition.
Canadian courts have explained that total disability can mean an inability to perform substantially all of the essential duties of a role. In a 1983 Supreme Court of Canada decision, Paul Revere Life Insurance Co. v. Sucharov, the court held that a person may still be considered totally disabled for insurance purposes even if some tasks are possible, where a reasonable person would agree that the injured person should not continue in that job.
Why Many Policies Change at 24 Months
While insurance policies vary, most LTD policies use the own occupation test for approximately the first 24 months. After about two years, many policies switch to a stricter any occupation assessment. At that point, even if you have been receiving benefits, your insurer may start to take steps to limit or terminate them.
Review your policy so that you understand whether and when the definition of disability will change, because this timing is controlled by the wording of your contract.
What Happens to Your LTD Claim After Two Years?
Many LTD policies contain a contractual change of definition. Around the 24 month mark, the insurer may stop using the own occupation test and begin applying an any occupation test to evaluate your disability.
Insurers often use the 24 month review to reduce or end LTD benefits, even if your medical condition is largely the same. They may claim that you can perform alternate work or argue that there is not enough medical evidence to show that you are disabled. In some cases, insurers arrange independent medical examinations, functional capacity evaluations, or other tests to support a position that you can take on other roles that pay a reasonable amount for your education and experience.
This change usually happens within a broader timeline such as:
- Before LTD starts. In most cases, you will stop working and use sick leave or short term disability benefits first.
- Approaching the end of short term disability. As short term disability benefits approach their end date, you will apply for LTD.
- During the waiting period. Most LTD policies have a waiting period, usually 90 to 180 days from when you become ill or injured, before LTD payments can begin.
- LTD approval and start of benefits. If you are approved for LTD, benefits begin once the waiting period ends.
- From 0 to 18 months. Your insurer monitors your claim by requesting periodic updates and medical information.
- From 18 to 24 months. Your insurer often starts to look ahead to the change of definition and may request updated medical reports and functional information.
- Near the 24 month mark. The insurer reviews your claim and tells you whether your LTD benefits will continue under the any occupation test or whether they will be stopped or reduced.
Review your policy to determine the specific timelines and procedures for your insurance plan.
What Documents Should You Submit Before the 24 Month Review?
At around 3 to 6 months before the 24 month mark, you may have an opportunity to update information with your insurer. Check your policy for the exact process. Sending updated medical evidence can help establish that you meet the any occupation test.
The evidence you submit will depend on your medical condition. You may provide recent reports and treatment notes from specialists and family doctors that describe your diagnoses, symptoms, restrictions, prognosis, and reasons you cannot perform any suitable job. You may also include test results such as laboratory work, imaging studies, psychological testing, and other relevant investigations.
Organizing this documentation early can place you in a stronger position when the insurer reviews your eligibility under the new definition.
How Insurers Assess ‘Any Occupation’
Every insurer has a slightly different process for assessing any occupation, but in general insurers examine whether you can perform any job that you are reasonably suited for based on your experience, training, and education. They cannot simply point to any job in the labour market. In general, suitable occupations must match your background, availability, level of responsibility, and overall status.
Insurers often use a Transferable Skills Analysis, which reviews your work history, occupational classifications, and medical restrictions to identify jobs they believe you could perform.
Canadian courts emphasize that any new work proposed must consider your whole profile and be reasonably comparable to your previous job. It should provide gainful income that is sustainable, and the insurer must show that you have a realistic chance of obtaining such work given your disability.
What Counts as a ‘Suitable’ Job Under the Any-Occupation Test?
If your insurer decides that you no longer qualify for disability benefits under the any occupation test, the insurer must explain which suitable jobs it believes are available to you with your current medical limitations.
These proposed jobs cannot be purely hypothetical. They must be actual, viable jobs you can do with your physical and cognitive condition. They must also be suitable for someone with your education and background.
Insurers consider several factors when assessing suitable jobs under the any occupation test:
- Education and training. Insurers look at degrees, certifications, on the job training, and specialized skills that qualify you for particular positions. For example, if you have a medical degree, that should limit proposed roles to work that recognizes that training.
- Work experience. Insurers are expected to consider your past roles and work experience, including transferable skills. If you worked in a professional role, you should not be pushed into low skill work that bears little relationship to your background.
- Medical restrictions. If your medical restrictions prevent full time work in a proposed role or prevent you from performing core tasks of that role, the insurer should not treat such work as suitable.
- Status and income. Any roles proposed by the insurer should have broadly comparable status and reasonable pay. If you held a leadership position, for example, the insurer should not rely on an entry level or low skill job as suitable. Often, a recommended role should provide at least a significant portion of your prior earnings to be considered gainful.
- Gainful employment. The insurer should propose work that is sustainable and gainful. That means roles that are not purely seasonal or temporary and that are geographically reasonable, so that you are not required to make a major relocation.
- Personal factors. Older workers and employees with limited opportunities for retraining should receive particular consideration, because securing reasonable work can be more difficult for them.
If you will be facing a review of your disability, start considering these factors in advance. Make sure that your medical documentation addresses your functional limitations and consider compiling work, education, training, and income records so you can respond if your insurer tries to push you into unsuitable work. If your insurer is not acting fairly, consult with a Hamilton long term disability lawyer.
How the Definition Affects Payments, Rehabilitation, and Return-to-Work
The definition of disability in your Ontario LTD policy directly affects how long benefits continue, how rehabilitation is managed, and what you must report to the insurer. Under an own occupation test, benefits generally continue as long as your condition prevents you from performing the essential duties of your regular job.
When the policy shifts to an any occupation test, the focus broadens to whether you can perform other work for which you are reasonably suited. This change often brings more scrutiny, and you may face a situation where the insurer tries to limit benefits based on vocational assessments or proposed jobs.
Claimants may be asked to participate in retraining or job search activities, particularly where medical restrictions allow some level of work. Insurers may also increase their monitoring of medical records and functional reports around the time of the change of definition.
The Financial Consumer Agency of Canada has a guide explaining the basics of disability insurance, but it remains essential to review your own policy to understand what your insurer will require. In general, insurers expect ongoing disclosure of medical progress, work attempts, and income. Failure to report changes such as starting part time work can result in overpayments or suspension of benefits, even if the underlying disability remains genuine.
Can You Work Part Time and Keep Some LTD Benefits?
In many cases, the answer is yes. Partial disability clauses often allow you to earn income while continuing to receive LTD benefits, subject to an offset formula. Typically, the insurer reduces benefits based on your earnings.
To protect your claim, report all work activity promptly, including hours, wages, and how the work affects your condition. Make sure that any part time work is consistent with your medical restrictions and that your doctors and insurer are informed.
Documentation, Monitoring, and Appeals at the Changeover
At the changeover between the own occupation and any occupation tests, documentation becomes especially important. Strong documentation is expected by insurers and is crucial in establishing that you qualify for benefits.
Review your policy carefully to understand exactly what your insurer requires and how often updates are needed. Many insurance companies will require medical updates, including an attending physician statement, which outlines any changes to your medical condition as well as details about treatment, prognosis, and the impact of your condition on your ability to perform the essential functions of work. Detailed information from medical providers can help. Insurers will also look to see that you have consistently followed treatment plans and have been receiving regular care.
Insurers may also require a functional abilities assessment, which provides details about your medical limitations and how they affect work capacity. If you work part time, you may need to provide pay stubs and employer confirmations as well.
Even with strong documentation, insurers may still deny or reduce benefits at the changeover. In that situation, it is important to understand your rights and timelines for internal appeals or legal action.
When Should You Talk to a Hamilton Disability Lawyer?
You should speak with a long term disability lawyer in Hamilton as soon as you receive a denial letter, a notice that your benefits will be reduced or ended, or a warning that the definition of disability will soon change. Early advice is especially important around key points such as the 24 month change of definition, after an independent medical examination is scheduled, or when your insurer starts to suggest that you can return to other work. At these stages, missed deadlines or incomplete responses can seriously affect your rights. When you contact my firm, you speak directly with me, not a call centre or an intake screener. I will review your policy, the insurer’s letters, and your medical information, explain in plain language where you stand, and outline the practical options available to you. An LTD denial in Ontario can cause significant stress and uncertainty for you and your family. If you are worried that your benefits are at risk or have already been cut off, contact me for a free consultation so that we can talk through your situation and begin to plan your next steps together.