HomeMy WebLinkAbout2000-423-642-774 Benfits Claimant 00-07-25 Decision
In the matter of an Appeal
Before
The Subcommittee of the
JOint Insurance Benefits Review Committee
Regarding Claim # 423-624-774
Chair: Felicity D. Briggs
Appearing for the Union: Don Martin
Appearing for the Em ployer: Lisa Compagnone
2
Included In the most recent collectIve agreement between the partIes are the folloWIng
1
provIsIOn
Article 22 - Grievance Procedure
Article 22.9 - Insured Benefits Grievance
22 9 1 An allegatIOn that the Employer has not provIded an Insured
benefit that has been contracted for In thIS Agreement shall be
pursued as a Umon gnevance filed under ArtIcle 22 13 (Umon
Gnevance)
229.2 Any other complaInt or dIfference shall be referred to the Claims
ReVIew SubcommIttee of JOInt Insurance Benefits RevIew
CommIttee (JIBRC) establIshed under AppendIx 4 (J OInt
Insurance Benefits RevIew CommIttee), for resolutIOn.
Appendix 4
JOINT INSURANCE BENEFITS REV IEW COMMITTEE
1 Name of Committee
The CommIttee shall be referred to as the JOInt Insurance Benefits RevIew
CommIttee
2. Purpose of Committee
The purpose of thIS CommIttee IS to facIlItate commumcatIOns between the Employer
and the OPSEU on the subJect of Group Insurance, IncludIng BaSIC LIfe Insurance,
Supplementary LIfe Insurance, Extended Health Insurance, Long Term Income
ProtectIOn Insurance, and such other negotIated benefits as may from tIme to tIme, be
Included In the Group Insurance Plane
It IS understood that the Group Insurance benefits to be proVIded to employees and the
cost shanng arrangements between the Employer and ItS employees shall be as set out
In any applIcable collectIve agreement or arbItratIOn award, and the matters for
conSIderatIOn by thIS CommIttee shall be only as set out In these terms of reference
3 Composition of Committee
The CommIttee shall be composed of an equal number of representatIves from the
Employer and from the OPSEU wIth not more than eIght (8) representatIves In total
At meetIngs of the CommIttee, each party may be accompamed by an Actuary to
proVIde techmcal advIce and counsel
1
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4 Duties of the Committee
The dutIes of the CommIttee shall consIst of the folloWIng
- Development of the specIficatIOns for the publIc tendenng of any negotIated
benefits whIch may be Included In the Group Insurance Plan (to cover the
bargaInIng umt only)
- DetermInatIOn of the manner In whIch the specIficatIOns wIll be made avaIlable
for publIc tendenng;
- ConsIderatIOn and eXamInatIOn of all tenders submItted In response the
specIficatIOns for tender and preparatIOn of a report thereon,
- RecommendatIOn to the Government of Ontano on the selectIOn of the Insurance
carner or carners to underwnte the Group Insurance Plans,
- ReVIew of the semI-annual finanCIal reports on the Group Insurance Plan, and
- ReVIew of contentIOUS claims and recommendatIOns thereon, when such claim
problems have not been resolved through the eXIstIng admInIstratIve procedures
The speCIficatIOns for tender wIll descnbe the benefits to be proVIded, the cost
shanng arrangement between the Employer and ItS employees, the past finanCIal
hIStOry of the Insurance plans, the employee data, the format for the retentIOn
IllustratIOn for each coverage and the finanCIal reportIng reqUIrements Tenders
shall be entertaIned by the CommIttee from any IndIVIdual Insurance carner actIng
solely on ItS own behalf ThIS shall not preclude such carner from arrangIng
reInsurance as may be necessary
The basIs for recommendatIOn of an Insurance carner(s) wIll Include the abIlIty of
the carner(s) to underwnte the plan, complIance of the carner's quotatIOn wIth the
speCIficatIOns for tender the carner's servIce capabIlItIes and the expected long
term net cost of the benefits to be proVIded.
1 Experience Review
2. Claims Review Subcommittee
(a) There shall be a subcommIttee whose mandate IS to reVIew and make
decIsIOns on, complaInts or dIfferences InvolvIng the demal of Insured
benefits under the Central CollectIve Agreement, when such Issues have
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not been resolved through the eXIstIng admInIstratIve procedures, save and
except a complaInt or dIfference ansIng under ArtIcle 22 9 1 (Insured
Benefits Gnevance) of the Central CollectIve Agreement. The
subcommIttee shall be composed of two (2) representatIves selected by the
Employer two (2) representatIves selected by OPSEU and an Independent
thIrd party who IS agreed to by both partIes
(b) Appropnate ImpartIal medIcal consultants shall be avaIlable to the
subcommIttee In an advIsory capacIty to provIde InformatIOn on the nature
of specIfic Illnesses or dIsabIlItIes
(c) MembershIp on the subcommIttee shall be for one (1) year penod, and IS
renewable at the dIscretIOn of the nomInatIng party or partIes In the case
of the renewal of the term of the Independent thIrd party
(d) DeCISIOns of the subcommIttee are final and bIndIng.
(e) The fees and expenses of the medIcal consultants referred to In clause (b)
and the Independent thIrd party referred to In clause (a), shall be dIvIded
equally between the Employer and the Umon.
Article 42 - Long Term Income Protection
Total dIsabIlIty means the contInUOUS InabIlIty as the result of Illness, mental
dIsorder or InJury of the Insured employee to perform the essentIal dutIes of hIS or
her normal occupatIOn dunng the qualIficatIOn penod, and dunng the first twenty-
four months of the benefit penod and thereafter dunng the balance of the benefit
penod, the InabIlIty of the employee to perform the essentIal dutIes of any gaInful
occupatIOn for whIch he or she IS reasonably fitted by educatIOn, traInIng or
expenence
Subsequent to the sIgmng of thIS collectIve agreement the partIes negotIated and
sIgned terms of reference regardIng the establIshment of a subcommIttee to deal WIth
dIsputes between the partIes regardIng Long Term Income ProtectIOn (hereInafter
referred to as "L TIP") That memorandum stated
JIBRIC CLAIMS REVIEW SUBCOMMITTEE
TERMS OF REFERENCE
AUTHORITY
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The JIBRC subcommIttee IS establIshed under ArtIcle 2292 and AppendIx 4 of
the collectIve agreement between The Crown In Right of Ontano and the Ontano
PublIc ServIce Employees Umon.
PURPOSE OF SUBCOMMITTEE
To reVIew and make decIsIOns on appeals from employees on claims InvolvIng the
demal of Insured benefits under the collectIve agreement whIch have prevIOusly
been removed from JIBRC
REFERRAL TO THE SUBCOMMITTEE
Employees wIth claims that have been removed from JIBRC wIll be notIfied of
such, In a tImely manner by letter (referred to as the "NotIce Letter") to theIr last
known address
An employee whose claim has been removed, has 45 days, from the date of the
notIce letter to submIt a request In wntIng to OPSEU askIng that OPSEU refer
theIr case to the subcommIttee ThIS letter must be copIed to the Management Co-
Chair of the JIBRC
OPSEU has 90 days from the date of the notIce letter to advIse the Management
Co-Chair of JIBRC of theIr decIsIOn to agree or deny the request to appeal If
notIce IS not receIved from OPSEU wIthIn 90 days from the notIce letter then the
claim wIll be deemed to be wIthdrawn.
SCOPE OF COMMITTEE
The SubcommIttee represents the final stage In the appeal process
The SubcommIttee wIll clanfy medIcal eVIdence as needed, wIth a medIcal
consultant agreed to by both MBS and OPSEU
DeCISIOns of the SubcommIttee are final and bIndIng.
Upon receIpt of the decIsIOn, a Memorandum of Settlement (as attached) wIll be
prepared and sIgned by the partIes and forwarded to the Insurer
SUBCOMMITTEE MEMBERSHIp.
The subcommIttee wIll conSIst of resource representatIves from OPSEU and MBS
and an Independent thIrd party "Chair" to be named by MBS and OPSEU
ROLE OF THE CHAIR
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To reVIew case representatIOns from MBS and OPSEU
To make a determInatIOns In wntIng wIth respect to each case DeCISIOns must be
In accordance wIth the OPS CollectIve Agreement between the Employer and
OPSEU and consIstent WIth the group Insurance plans In place at the tIme facts
gIVIng nse to the dIspute arose
ROLE OF MEDICAL CONSULTANTS
Appropnate ImpartIal medIcal consultants wIll be agreed by the partIes and shall
be avaIlable to the SubcommIttee In an advIsory capacIty If the partIes cannot
agree on a medIcal consultant, the Chair may call on a consultant from a roster
supplIed by the College of PhysIcIans and Surgeons
The medIcal consultants wIll provIde InfOrmatIOn on the nature of specIfic
Illnesses or dIsabIlItIes
The Chair may request an InterpretatIOn of medIcal reports, test results and other
medIcal documentatIOn on file
The medIcal consultant IS not a member of the commIttee and wIll not provIde an
OpInIOn related to a decIsIOn on the appeal
FEES
Fees and expenses, as approved by the partIes, of medIcal consultants and the
Chair shall be dIvIded equally between MBS and OPSEU
FORMA T OF MEETINGS
Each appeal wIll be dealt wIth separately
Both partIes, through theIr representatIves wIll provIde, full dIsclosure of the
supportIng documentatIOn upon whIch they Intend to rely ThIS dIsclosure wIll
take place at least two weeks In advance of the meetIng of the subcommIttee
dealIng wIth the subJect matter of the appeal
If the Chair reqUIres clanficatIOn of medIcal eVIdence, a meetIng of the
SubcommIttee wIll be arranged wIth a medIcal consultant agreed to by both MBS
and OPSEU or faIlIng such agreement, wIth a medIcal consultant called by the
Chair
MBS and OPSEU wIll JOIntly present a statement of agreed upon facts (to the
extent possIble) for the appeal to the Chair
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ASIde from the ImpartIal medIcal consultant dIscussed above, no other wItnesses
wIll be called, except by request of the Chair However the IndIVIdual claimant
wIll be allowed to file a wntten statement In lIeu of testIfYIng. If the IndIVIdual
claimant chooses to file a statement It must be provIded to the Management Co-
Chair of JIBRC at the same tIme as OPSEU's request for appeal MBS has the
nght to Introduce a wntten response to thIS statement.
OPSEU wIll present ItS posItIOn on the case wIth supportIng arguments to the
Chair MBS wIll present ItS posItIOn on the case wIth supportIng arguments to the
Chair and wIll respond to OPSEU's posItIOn. OPSEU wIll have nght of reply
PresentatIOn by both partIes wIll be based upon the InformatIOn/record on file
before the Insurance carner at the tIme the matter IS removed from the JIBRC the
employee statement If any and MBS's response to the statement.
EIther party may If necessary request the attendance of the claimant, who shall be
allowed a leave of absence wIthout pay wIth no loss of credIts, to attend the sub-
commIttee meetIng as an observer only
The Chair wIll render a wntten decIsIOn wIth supportIng ratIOnale
FREQUENCY OF MEETINGS.
On an as needed basIs as determIned by MBS and OPSEU JOIntly
The partIes agree to these Terms of Reference In support of the ImplementatIOn of
ArtIcle 22 9 2 and AppendIX of the collectIve agreement.
It was preVIOusly agreed by the partIes that a decIsIOn should sImply IndIcate whether a
claim was properly or Improperly demed. The Chair IS to refraIn from elaboratIng on the
quantum of the remedy but rather remaIn seIzed. Subsequent to the Issuance of the
decIsIOn the partIes wIll negotIate and execute a memorandum of agreement that wIll
Include the appropnate remedy
Dunng the term of the prevIOUS collectIve agreement, the partIes attempted to resolve
these dIsputes between themselves Not surpnsIngly there were a number of Instances
when consensus was not achIeved. Those matter sImply remaIned unresolved. Those
outstandIng matters are now beIng brought forward before the subcommIttee as set out
above
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The partIes filed an agreed statement of fact In thIS matter that stated
1 Mr D W began to work wIth the government on May 6 1974
2 Mr D W stopped workIng on May 5 1995
3 At the tIme when he stopped workIng, Mr DW was a Semor ConstructIOn
TechmcIan (Highway ConstructIOn Inspector 2)
4 Mr D W 's STTP benefits ended on November 6 1995
5 Mr D W applIed for LTIP benefits on September 14 1995
6 ManulIfe demed hIS claim on January 12, 1996
7 Mr D W appealed the demal to ManulIfe on May 3 1996
8 ManulIfe demed the appeal on June 25 1996
9 Mr D W ' s claim was removed from the table at JIBRC on May 24 1997
10 Mr D W seeks LTIP benefits from November 1995 untIl hIS return to work at the
end of January 1997
In the claimant's statement to ManulIfe dated September 14 1995 he Said the nature of
hIS Illness was "nerves gettIng bad agaIn could not control nerves"
Dr C S Mr D W's famIly physIcIan, stated, In the October 12, 1995 physIcIan's
statement, that hIS dIagnosIs was "anxIety - pamc attacks" He further wrote that
subJectIve symptoms were "fast heart beat, sweatIng, tremor nervousness" Dr C S
IndIcated that the claimant was on medIcatIOn. It was explaIned that Mr D W was unable
to concentrate and had pamc attacks Under prognOSIS It was stated that Dr C S thought
that "he should soon be ready to return to work" but that he "probably should do part tIme
for 2 - 3 weeks and gradually return to full tIme" Finally In the remark sectIOn Dr C S
stated "moderately severe anXIety WIth pamc dIsorder - questIOnable exceSSIve use of
alcohol" (emphaSIS not mIne)
A claims adJudIcator from ManulIfe wrote to Dr C S requestIng further InformatIOn. He
reply was In a letter dated November 13 1995 He Said
ThIS IS In reply to your letter of October 31 st 1995 1995 re Mr D W Mr D W
was seen first on June 1 1995 He had been off work SInce May 23 1995 because
of ongOIng problems WIth severe anXIety and pamc dIsorder He was seen by me
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seven tImes between June 1 st 1995 and October 19th 1995 He was treated wIth
Lectopam and Toframl and counselIng. I saw hIm last on October 19 1995 At
that tIme, he felt that he was ready to go back to work. We agreed that he would
return to work on October 23rd 1995 and that he would work half days for one
week and then return to full duty He was to see me If there were any further
problems
The claimant dId attempt to return to work. ThIS IS explaIned In a letter wntten by the
employer's representatIve to the claims adJudIcator In a letter dated November 27 1995
It was stated
Mr D W returned to work for 4 hours per day October 24 to November 3rd
InclUSIVe Mr D W has been off work from November 4 1995 and exhausted hIS
sIck credIts as of 1200 pm November 9 1995
In thIS regard, there was a letter dated November 16 1995 from Dr C S that said
Mr C W has not been able to work last week and thIS present week (November
6th - 16th InclUSIve) He wIll not be able to return to work to untIl further notIce
The claims adJudIcator then wrote to Dr C S on November 27 1995 That letter stated,
In part
We have receIved the report dated November 13 1995 whIch you submItted on
behalf of Mr D W In thIS report, you IndIcated that on October 19 1995 you felt
Mr D W was ready to go back to work. He was to return on October 23 1995
workIng half days for one week and then return to full duty We have been
advIsed by Mr D W's employer that he dId return to work on a part tIme baSIS,
however he only worked for three days and had to dIscontInue
To further assIst US In our evaluatIOn ofMr D W 's claim and to better understand
the extent of hIS dIsabIlIty we would appreCIate a narratIve report from you
descnbIng hIS current condItIOn, any complIcatIOns, treatment IncludIng drugs and
dosages, frequency of VISItS, complIance wIth your recommended treatment plan,
proposals for returmng to work, copIes of all relevant consultatIOn notes and
InVestIgatIOn reports In support of the dIagnOSIS What changed In hIS condItIOn
that prevented hIm from contInuIng hIS return to work. Has Mr D W been
referred to a PsychIatnst?
We InVIte your addItIOnal comments
A form 14 authonzatIOn for the release of the requested InformatIOn was sent to
you on November 15 1995 Should you prefer you may address your response
dIrectly to Dr B S PsychIatnc MedIcal Consultant Group Insurance
Dr C S wrote to ManulIfe on December 18 1995 the folloWIng
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ThIS IS In reply to your letter of November 2ih 1995 concermng Mr D W He dId
return to work on October 23rd 1995 but was not able to contInue He has been off
work SInce November 6th 1995
As per your suggestIOn, I am dIrectIng a more detaIled report to Dr B S I am
hopIng that Dr B S wIll be able to see Mr D Wand If there IS anythIng you can
do to expedIte thIS I would be most grateful
In that letter to Dr B S Dr C S stated the folloWIng:
I have been asked, by Lynda Dewar to commumcate wIth you regardIng Mr D
W Mr D W has been seeIng me on and off for the past two or three years wIth
complaInts of severe anxIety He has usually responded to reInforcement therapy
and treatment wIth mInor tranqUIlIzers SInce May of 1995 he has been off work
wIth severe anxIety and pamc dIsorder He has been takIng Toframl and
Lectopam In spIte of these medIcatIOns, he IS stIll unable to return to work
because of hIS anxIety He says he IS unable to concentrate and cannot focus on hIS
work. He becomes anxIOUS that someone may get hurt because of hIS lack of
concentratIOn.
ThIS IS the InformatIOn he volunteers but I suspect there IS a greater underlYIng
problem here Each tIme I see hIm, he has a smell of alcohol on hIm In August, I
had a lIver ultrasound done whIch suggested there was a "fatty metamorphOSIS"
His ASOT was elevated at 90 (normal 9 - 34) alkalIne phosphate was 148
(normal 30 - 103) and total bIlIrubIn was 21 (normal 2 - 18)
ThIS has me concerned that he may be haVIng a problem WIth alcoholIsm and IS
not volunteenng thIS pIece of InfOrmatIOn. Up untIl now he has not seen a
psychIatnst. (It IS not easy to get a psychIatnc consultatIOn up In the North.) I am
wondenng If It would be proper for you to evaluate hIm and, If so could you
please arrange an appoIntment.
Mr D W was seen by a psychIatnst, Dr G G In early March of 1996 He wrote a
consultatIOn report to Dr C S that said
I would lIke to thank you for askIng me to see thIS 40 year old man who I saw on
March 2, 1996
When I met WIth Mr D W today he appeared qUIte shaky anxIOUS, and he
wanted to make a good ImpreSSIOn. He stnkes me as someone who has had a long
standIng dnnkIng problem His anXIety dIsorder has been a problem for hIm at
least 15 years, and he apparently has been on vanous kInds of pIll for thIS He
explaInS that he IS a semor Inspector on constructIOn, and throughout the IntervIew
I sensed that he wanted to Impress me WIth the work that he does In any case, he
IS rather fearful to return to work, and probably hIS anXIety IS out of control to
some degree He does need help to get back Into the work force, and I would hope
he makes It back because he IS only 49 years of age
He IS qUIte a dependent man who comes from a very Impovenshed background.
He IS one of eIght chIldren, and he has a few memones of hIS chIldhood untIl
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about age 11 From hIS descnptIOn of thIngs, the famIly moved around a lot, and
there was lIttle kIndness or conSIderatIOn. He referred to hIS mother as a hard
woman and does not ever remember gettIng affectIOn from her He tells a story of
leavIng the famIly home at age 12 to go to Wallaceburg to lIve WIth hIS sIster and
who he worked (sic) In the tobacco fields He ImplIes by thIS story that hIS parents
dId not care what happened to hIm and that he had to face lIfe on hIS own at a
young age He returned to the area and eventually met hIS present wIfe, and she
got pregnant when he was about 18 He has become qUIte dependent on her and
fortunately for hIm, she has been qUIte a strong support. He told me that hIS "lIfe
started when I met my wIfe" His parents were not In favour of thIS relatIOnshIp
and he tell a (sic) story of how hIS father offered hIm a hundred dollars to
dIsappear when he dIscovered that she was pregnant. He has made a sound
marnage and has tned to be a good father He IS very proud of hIS boys and has
tned to reverse some of the damage that was done to hIm when he was a chIld and
has been a canng father He has a vasectomy as (sic) a rather young age whIch
made me wonder If he feared the responsIbIlIty of a large famIly His wIfe has
worked and supports hIm
He has worked In hIS present Job for the mImstry for 23 years He has worked hIS
way to beIng a semor Inspector and he talked of how he has had to be tough WIth
people ThIS IS not easy for hIm because I suspect he IS rather fnghtened of people
underneath. His phobIas come out In terms of hIm not beIng able to work Indoors,
and he has always had to work out In the field. He wanted to talk about hIS
penSIOn whIch I really dIdn't want to get Into It seems that he has been turned
down for hIS long-term dIsabIlIty protectIOn, and he IS angry about thIS because
(sic) entItled to receIve the money
In terms of managIng hIm, I would be qUIte happy to see hIm once a month when I
come to town. I would deal WIth hIS anXIety and pamc by puttIng hIm on a drug
such a (sic) Aventyl gIVIng hIm a 75 mg q.h.s the tncyclIc antI-depressants are
very effectIve In dealIng WIth anXIety over a long penod of tIme and I thInk the
medIcatIOn also would help In the area of hIS mIld depressIOn. Mr D W has
fightIng back tears throughout hIS entIre IntervIew WIth me, and I thInk he fees
down and deflated. I would suggest that he stop dnnkIng, and I would gradually
wean hIm off of Lectopam.
There was another letter from Dr G G after a VISIt on May 2, 1996 It stated
Mr D W asked If I would wnte to you about hIS VISIt WIth me today I found hIm
to be rather shaky and he seems very concerned about hIS dIsabIlIty penSIOn. He
wanted to talk repeatedly about the SItuatIOn because he feels that he IS entItled to
penSIOn benefits, and for whatever reason thIS IS beIng WIthheld.
SInce he has been on Aventyl he IS now sleepIng better but unfortunately he ran
out of hIS medIcatIOn and has gone for two weeks WIthout takIng any Generally
people do not respond to Aventyl untIl they have taken theIr medIcatIOn for SIX to
eIght weeks, and he has probably only taken about four weeks of medIcatIOn.
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He wanted me to wnte to hIS Insurance company today about hIS pensIOn benefits
I explaIned to hIm that the company should wnte to me askIng for specIfic
InformatIOn, and that I would then comply and answer theIr letter I do thInk there
IS a sIgmficant depreSSIve sIde to hIS symptoms and that wIth an antIdepressant
drug that he should make a recovery In any case the Aventyl also should help hIS
symptoms of pamc I questIOned hIm today as to how much he IS dnnkIng, but he
possIbly mImmIzes thIS tellIng me that he only dnnks one or two beers a day I
also encouraged hIm to cut down on hIS Lectopam. I suggested to Doug today that
he take Aventyl 25 mg at 6pm and 75 mg at bedtIme I have asked hIm to return
next month for a follow up VISIt.
I was provIded wIth a memorandum wntten by a DIsabIlIty SpecIalIst to the Claims
AdJudIcator In charge ofMr D W 's file It was wntten on June 20 1996 and said
Lynda, I'm not really In agreement wIth contInuIng to tell thIS man that the
medIcal eVIdence doesn't support dIsablIng Illness and he Isn't complYIng wIth
proper treatment. If we feels he needs to under appropnate treatment, then clearly
we have Inferred from the medIcal eVIdence that he does have an Illness and thIS
IS ObvIOusly alcoholIsm
In hIS report of Dec 18 Dr C S IndIcated that he was certaIn the man's problem
was alcohol abuse and he appealed to us for help because of the lack of
psychIatnc help In Northern Ontano I feel that at the tIme, rather than SImply
declImng the claim, we should have set up a psych !ME If the psych. concurred
WIth Dr C S that the maIn problem was alcoholIsm, we could then have advIsed
the claimant to arrange for ImmedIate referral to an appropnate treatment faCIlIty
and benefits would be conSIdered once we had been advIsed by hIS doctor as to
the name of the faCIlIty and the date of admIssIOn.
AgaIn, I thInk that contInuIng to SImply declIne the claim Isn't really fair to thIS
man, who, accordIng to Dr G G IS currently TD Had the claimant been lIvIng In
Toronto or London he would probably have been referred to a psych. long before
he was, and would have had a better chance of havIng hIS problem IdentIfed and
referral to a proper treatment faCIlIty made
I suggest adVISIng the claimant that we have receIved Dr G G 's report and thIS,
together WIth the entIre file, has been revIewed In conJunctIOn WIth out Psych.
Consultant. FollOWIng thIS reVIew It has been determIned that the medIcal
eVIdence clearly ImplIes that, whIle you may have other problems, alcoholIsm IS
the pnncIpal dIagnOSIS responSIble for your complaInts AccordIng to the polIcy
the claimant must be reCeIVIng care and treatment satIsfactory to ManulIfe
Therefore, In order to be elIgIble for benefits, you must be referred to a faCIlIty for
the treatment of alcoholIsm and you must comply WIth the program of the faCIlIty
Therefore we recommend that you dISCUSS referral to a substance abuse treatment
faCIlIty WIth Dr G G and Dr C S Please have your doctor proVIde us WIth the
name of the faCIlIty and date of admIssIOn, as soon as the arrangements have been
made, In order for us to conSIder your entItlement to Long Term Income
ProtectIOn Benefits
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To preserve confidentIalIty a more general letter could go to the Mimstry adVISIng
that we have receIved addItIOnal medIcal eVIdence, but after reVIew of thIS, we
have determIned that Mr D W IS not under care and treatment satIsfactory to
ManulIfe, as reqUIred by the contract. Therefore, we have advIsed hIm to dISCUSS
admIssIOn to an appropnate facIlIty wIth hIS doctor and let us know what
arrangements have been made We wIll then consIder the release of benefits
Currently our decIsIOn to declIne remaInS unchanged. AdvIse that a more detaIled
letter has been forwarded to Mr D W
Apparently In accordance wIth thIS memorandum, Ms Lynda Dewar wrote to the
claimant on June 25 1996 adVISIng, In part, the folloWIng
We have receIved the appeal submItted on your behalf by Dr C S
As you are aware, In order to be elIgIble for LTIP benefits, you must be wholly
and contInuously dIsabled by Illness or aCCIdental bodIly InJury whIch prevents
you from performIng the essentIal dutIes of your normal occupatIOn.
Your group polIcy further stIpulates that you must be under ongOIng and
contInUOUS medIcal supervISIOn and treatment conSIdered satIsfactory to ManulIfe
FinanCIal Group Benefits
The appeal conSIsted of consultatIOn reports completed by Dr G G on Mary 2,
1996 and May 2, 1996 Dr G G ' S report together WIth the entIre file, has been
reVIewed In conJunctIOn WIth out PsychIatnc MedIcal Consultant. FollOWIng thIS
reVIew It has been determIned that the medIcal eVIdence clearly ImplIes that whIle
you may have other problems, alcoholIsm IS the pnncIpal dIagnOSIS responSIble
for your complaInts AccordIng to the polIcy the claimant must be reCeIVIng care
and treatment satIsfactory to ManulIfe FinanCIal Group Benefits Therefore, In
order to be elIgIble for benefits, you must be referred to a faCIlIty for the treatment
of alcoholIsm and you must comply WIth the program of the faCIlIty
Therefore we recommend that you dISCUSS referral to a substance abuse treatment
faCIlIty WIth Dr G G or Dr C S Please have your doctor proVIde us WIth the
name of the faCIlIty and the date of admIssIOn, as soon as the arrangements have
been made, In order for us to conSIder your entItlement to Long Term Income
ProtectIOn benefits Once we have receIved thIS InfOrmatIOn, we wIll then
conSIder the release of benefits Currently our deCISIOn to declIne your claim
remaInS unchanged.
It was the Umon' s pOSItIOn that the claimant's dIagnosed condItIOn was anXIety and pamc
dIsorder not alcoholIsm as stated In the above letter The documentatIOn before the Chair
IndIcates that the claimant was totally dIsabled as the result of hIS dIagnOSIS and therefore
he was entItled to L TIP If ManulIfe thought that the claimant was an alcoholIc It had an
opportumty to InVestIgate that matter It could have ordered an Independent medIcal
OpInIOn and It faIled to do so Instead It opted to create ItS own dIagnOSIS and SubstItute It
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14
for the dIagnosIs provIded by the only two medIcal doctors who actually saw the
claimant.
The Employer suggested that there IS a debate as to whether the appropnate dIagnosIs IS
anxIety dIsorder or alcoholIsm Further there IS nothIng In the documentatIOn that
explaIns why the claimant IS totally dIsabled other than a reference to a lack of
concentratIOn. It was urged that obJectIve testIng should be preferred when consIdenng
the eVIdence Those results IndIcate lIver dysfunctIOn as IS often found In alcoholIsm
Moreover the claimant's symptoms as lIsted by the physIcIans are the same as symptoms
of alcoholIsm That InformatIOn coupled wIth Dr G G ' S suggestIOn that the claimant
should qUIt dnnkIng alcohol must lead to a demal of the appeal
DECISION
After consIderatIOn, I have decIded to uphold thIS appeal In arnVIng at thIS determInatIOn
I have found the June 20 1996 memorandum wntten by the DIsabIlIty SpecIalIst to the
Claims AdJudIcator both enlIghtemng and dIsturbIng. In that memorandum It was stated
that the Insurance company had "Inferred from the medIcal that he does have an Illness
and thIS IS ObvIOusly alcoholIsm" and that Dr C S was "certaIn" that the claimant's
problem was "alcohol abuse" AccordIng to the eVIdence before me, thIS IS sImply
Incorrect. Dr C S IndIcated In hIS attendIng physIcIan's statement that there was a
"questIOnable" exceSSIve use of alcohol (emphasIs not mIne) Later In hIS letter to
ManulIfe's psychIatnc medIcal consultant, he Said that the claimant "may be havIng a
problem wIth alcoholIsm and IS not volunteenng thIS pIece of InfOrmatIOn" I do not
accept that those two statements represent a certaInty that the claimant has " ObVIOUS
alcoholIsm"
I accept that there IS eVIdence that mIght well lead one to such a SuspICIOn. However It
was Inappropnate for ManulIfe to sImply SubstItute ItS VIew over the stated dIagnosIs of
record and other medIcal InformatIOn. In my VIew If ManulIfe suspected there was an
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15
Improper dIagnosIs and/or method of treatment, It could have, and should have, asked for
an Independent medIcal evaulatIOn. Surely thIS IS precIsely the type of sItuatIOn where an
Independent medIcal evaluatIOn IS the appropnate tool to determIne accuracy of dIagnosIs
and prescnbed treatment. ThIS was acknowledged by the DIsabIlIty SpecIalIst when s/he
advIsed the claim adJudIcator on how to proceed wIth the claimant's file
Moreover It seems to me that In arnvIng at ItS Inference ManulIfe dIscounted or
completely Ignored the claimant's consIderable hIStOry regardIng hIS anxIety dIsorder In
hIS December 18 1995 letter to the psychIatnc medIcal consultant Dr C S IndIcated that
he had been seeIng the claimant for the "past two or three years wIth complaInts of severe
anxIety" and that Mr D W had "responded to reInforcement therapy and wIth mInor
tranqUIlIzers" ThIS InformatIOn should have buttressed the credIbIlIty of Dr C S ' S stated
dIagnOSIS, not lead to a dIfferent VIew
What I find most surpnSIng about the June 20 1996 memorandum IS that the DIsabIlIty
SpecIalIst appears to determIne the dIagnOSIS of alcoholIsm and makes the findIng that the
claimant IS not reCeIVIng the proper or appropnate treatment before the file IS reVIewed by
the psychIatnc medIcal consultant. Indeed, the DIsabIlIty SpecIalIst suggests the file
outcome even before there has been any medIcal reVIew One mIght be InclIned to thInk
that It would not have mattered what the VIew of the medIcal consultant was or whether
that OpInIOn could have had any Impact on the final decIsIOn of the claim adJudIcator The
fact that the words used In the final demal of the claim are a dIrect quote from the
memorandum only reInforces that SuspICIOn.
The Employer argued that, IrrespectIve of dIagnOSIS, neIther phYSICIan ever partIculanzed
why the claimant was totally dIsabled and the faIlure to do so should lead to a demal of
thIS appeal WhIle I agree that thIS IS a case where there IS not the level of speCIfiCIty that
mIght be helpful regardIng the claimant's dIsabIlIty a phYSICIan's lack of detaIls, even In
the face of requests for more InfOrmatIOn, cannot be suffiCIent to deny an otherwIse
legItImate claim. I acknowledge that In the Instant case there was a dearth of speCIfics
Clmm#423-624-774
16
from the attendIng physIcIans However Dr C S stated that the claimant was unable to
concentrate and had pamc attacks He lIsted the subJectIve symptoms as fast heart beat,
sweatIng, tremor and nervousness It IS understandable that In Instances of a psychIatnc
dIagnOSIS It wIll be dIfficult to artIculate dIsablIng factors In a sImIlar fashIOn as would be
found wIth a physIcal dIsabIlIty InterestIngly In the June 20 1996 memorandum the
DIsabIlIty SpecIalIst acknowledges that Dr GG found the claimant to be totally
dIsabled.
In thIS matter the Employer IS askIng for a findIng from the Chair that devIates from the
face of the record. There IS a sIgmficant onus on a party seekIng such a devIatIOn to
proVIde eVIdence that would JustIfy such a findIng.
The partIes have negotIated a procedure that reqUIres them to put theIr case before the
subcommIttee by way of documentary eVIdence Although viva voce eVIdence can be
called In certaIn CIrcumstances If deemed appropnate by the Chair the process, In large
measure, allows the partIes an efficIency of lItIgatIOn that IS rarely seen In labour relatIOns
matters I am concerned that the Employer IS askIng me to come to my own conclUSIOn
that IS not substantIated by the documentary record of the claimant.
The Insurance company had at ItS dIsposal the means at the tIme to challenge the
dIagnOSIS of record. It chose not to do so and It cannot now expect the subcommIttee to
make Inferences that contradIct the documents It IS not the role of the Chair to dIagnose
claimant's condItIOns Our role IS SImply to Interpret the medIcal InformatIOn and other
documentary eVIdence agaInst the test for total dIsabIlIty
For all those reasons, the appeal IS allowed.
Date In Toronto thIS 25th day of June, 2000
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Clmm#423-624-774