Glossary

A letter stating someone is unable to work, without the observations, measurements or tested tolerances that would support that statement.

Conclusions are the practitioner’s opinion. Findings are evidence. Files are decided on findings, and a well-meaning letter of support with nothing underneath it can do less than nothing.

A period where the file shows no appointments, no therapy and no contact, with nothing in the record explaining why.

Gaps are read as improvement unless something says otherwise. If there was a waitlist, a cost barrier, a referral delay or a relapse, it needs to be documented somewhere in the file at the time.

Files that describe how someone feels without addressing function, capacity, treatment response or objective assessment.

Mental-health claims are not held to a lower evidentiary standard — often the opposite. Functional documentation matters more here, not less.

A condition of coverage taking effect: the employee must be performing their duties on the date coverage or an increase would begin.

Why timing a plan change while someone is off sick is dangerous. Their increase may simply not take effect, and nobody notices until a claim.

10% of the claim amount, charged by the HSA administrator.

This is negotiable and varies by provider. Halving it materially changes the result.

Moving from a 10% fee to a 5% fee directly reduces the cost of the HSA route.

Worth negotiating, and worth comparing between administrators rather than accepting the first quoted.

The employer self-funds claims and pays an insurer to adjudicate and administer, normally with stop-loss protection above a threshold.

Needs meaningful size and stable claims, and applies to health and dental only — never disability. On a small group it transfers volatility to an employer who cannot absorb it.

The same instrument under a different name, depending on insurer and jurisdiction.

Use whichever term appears on the insurer’s own form.

A ceiling on total income from all sources while disabled — LTD, CPP disability, workers’ compensation, other coverage — commonly around 85% of pre-disability net income.

Explains the outcome people find hardest to accept: a member is approved for CPP disability and their LTD payment falls by the same amount.

The tendency of people who expect to claim to buy more coverage, and people who do not to buy less — which, unchecked, drives the healthy out of a pool and spirals the rate.

Nearly every restriction in group insurance exists to defeat it: mandatory participation, waiting periods, late-applicant penalties, medical evidence, actively-at-work rules. Far better than “because the contract says so” when explaining a rule to staff.

A formal appeal supported by documentation that addresses the specific ground on which the claim was refused.

An appeal that simply restates the original position rarely succeeds. The appeal has to answer the reason given for the denial, which means reading that reason precisely.

The three dental tiers. Basic is diagnostic, preventive and fillings; major is crowns, bridges and dentures; orthodontic is separate, usually with its own lifetime maximum.

Watch for a combined basic-and-major maximum, which is much less generous than it sounds — one crown can consume the year’s allowance for both.

The person nominated to receive a death benefit, recorded on the member’s enrolment form.

Stale designations are endemic and consequential — a death benefit paid to an ex-spouse is unrecoverable. A beneficiary refresh is a low-effort, high-value exercise on any plan that has not done one in years.

How the amount is derived — a flat amount for everyone, a salary multiple such as one or two times annual earnings, or a schedule varying by class of employee.

A salary multiple keeps coverage current as pay rises but interacts with the non-evidence maximum. A flat amount is simple and quietly erodes in real terms.

Whether amounts already used in the year under the prior plan count against the new plan’s maximums.

Frequently overlooked. A member who has used their dental maximum may find it either reset or preserved — and either answer produces a phone call if nobody said which.

A signed instruction from the plan sponsor to the insurer appointing a new broker on an existing policy. It transfers servicing rights and commission. It does not change the contract, the rates, the insurer or the coverage.

Nothing about your coverage moves and nobody re-enrols. Your plan, your carrier, your rates and your members’ cards all stay exactly as they are. Only the adviser changes.

A federal dental program for eligible residents without access to employer or private dental coverage. Access to an employer dental plan generally disqualifies a person from it.

This changes a real conversation. An employer considering dropping dental should understand it may push staff toward a public program with its own eligibility tests rather than simply removing a benefit. Verify current rules before relying on this — the program is still being phased in.

Canadian Life and Health Insurance Facts — disability statistics.

The standard industry reference for Canadian disability incidence and benefits data.

Taking the plan to market and managing competing quotes.

Timing matters more than effort — insurers quote meaningfully sixty to one hundred and twenty days out.

Advocating on the interpretation and application of the contract when a claim is disputed.

Scope varies enormously between brokers. Worth establishing what yours actually does when a member’s claim is refused, before it happens.

The share of an eligible expense the plan reimburses — 80%, 90% or 100% — with the member paying the rest.

The most powerful cost lever and the most under-used. Moving from 100% to 90% on health typically returns mid-single digits, because member cost-sharing suppresses discretionary use. A plan at 100% has surrendered that lever entirely, and some small-group markets will load or decline it.

Commission is a percentage of premium built into the rate, varying by line — richest on health and dental, thinner on life and disability. A servicing fee is a flat negotiated amount replacing commission, disclosed to the client.

Commission sits inside retention, which means it is part of what you pay whether or not your broker does anything. Asking what your broker is paid is a fair question and a good one.

Ensuring the plan and the advice meet regulatory requirements, including disclosure of how the broker is compensated.

You are entitled to ask how your broker is paid on your plan. A straight answer is the minimum standard.

A one-time review of a file by an external clinical consultant, used to identify what the file is missing before a formal decision point.

Comparatively small cost against the reserve attached to a long-term disability claim, and most useful before a change-of-definition date rather than after a denial.

Whether and how coverage continues during parental leave, disability or a temporary layoff, and who pays the premium.

Statutory leave rules and contract rules are not the same thing. Check both before stopping remittance for someone on leave.

Contract workers are ordinarily not eligible under a group contract, which insures employees. Part-time eligibility turns on the minimum-hours definition in the contract.

Enrolling an ineligible person is worse than not enrolling them: premium is collected, everyone believes coverage exists, and the claim is denied. Verify eligibility before adding anyone.

The right to convert group life to an individual policy on termination without medical evidence, generally within thirty-one days.

Short and absolute. An employer who fails to inform a departing employee — particularly one leaving because of illness — has real exposure. It belongs on the termination checklist.

Where two plans cover the same person, the rules deciding which pays first. A member’s own plan is primary for themselves; for children, the parent whose birthday falls earlier in the calendar year is primary.

A group with many dual-covered spouses will show a better loss ratio than its plan design suggests — genuinely useful when explaining unusually good experience.

12.2% small business rate applied to the corporation.

The lower the corporate rate relative to the personal rate, the larger the advantage.

A federal benefit for those with a severe and prolonged disability preventing substantially gainful work. Approval is difficult and the standard is stricter than most LTD contracts.

LTD insurers routinely require claimants to apply, because an award offsets their liability. Members experience that as being pushed toward a benefit they will probably be denied — explaining why it is required defuses a common and genuine grievance.

The weight an insurer gives your own claims versus their pooled manual rate. Driven by group size, and sometimes by claim volume rather than headcount.

Below roughly fifty lives, credibility is low and often zero at a new insurer. A credibility figure that never moves across years — 50%, 50%, 50% — tells you a size-band formula is being applied rather than a genuine evaluation of your group.

An amount the member pays before the plan responds — annual or per-prescription, per person or per family.

A small per-prescription deductible is among the least painful savings on a rich plan. Members barely register a few dollars a script, and claim volume drops measurably.

The gap between premium and what the experience says premium should have been. A deficit may be carried forward and recovered through future rates; a surplus may be returned or held, depending on the accounting basis.

Ask outright whether a carried-forward deficit exists before marketing a plan. It can follow a group out the door, and it is often the hidden reason a renewal looks punitive.

What counts toward insured salary — base only, or base plus bonus, commission or overtime, and averaged over what period.

Critical for commissioned or variable-pay staff. A base-only definition can insure a fraction of someone’s real income, and they will not discover it until they claim.

The provincial dental association’s suggested fee schedule. Plans reimburse at the current year’s guide or a lagged prior year.

A lagged guide is a quiet saving and a quiet member irritation — they get balance-billed the difference. Always identify which guide a quote uses.

Spouse, and children to a stated age — commonly 21, extended to around 25 for full-time students, and indefinitely for a disabled child.

Student status usually needs annual recertification. A missed recertification means a nineteen-year-old’s claims are declined.

Members not actively at work on the takeover date must be individually disclosed to the incoming insurer.

Non-disclosure is the most serious error possible on a takeover. An insurer that learns at claim time of an undisclosed absent employee can rescind, leaving the employer with an uninsured liability.

A ceiling on the pharmacy fee the plan reimburses per prescription, independent of the drug cost.

Invisible to most members, meaningful in aggregate, and it nudges people toward lower-fee pharmacies and ninety-day fills. One of the cleanest savings available.

No. A quote is an analysis. It does not touch your contract, your insurer, your rates or your members’ coverage, and nothing changes unless you decide to act.

Nobody re-enrols and no card stops working. You simply end up with a comparison you did not have.

The Health Canada number identifying a specific drug product. Adjudication runs on the DIN, not the drug’s name.

When a member says their drug is not covered, the answer is nearly always DIN-level — a different manufacturer, strength or format of the same molecule. Ask for the DIN before escalating anything.

Federal income replacement during illness for eligible workers, for a defined number of weeks at a percentage of insurable earnings up to a maximum.

This is what usually bridges to LTD where there is no short-term disability plan. Knowing the current duration and maximum lets an employer see exactly what their people would live on.

The defined group entitled to coverage — for example, all permanent full-time employees working a minimum of 24 hours per week. Classes can be split to give different benefit levels to different groups.

Classes must rest on objective criteria, not names or preference. A class built to advantage one individual will not survive scrutiny at claim.

The volume of care actually routed through the account. Eligible categories include glasses and eye exams, dental, physiotherapy and prescriptions.

Most owners under-use the account because they forget it exists mid-year. The saving only materialises on spend that actually goes through it.

The wait between disability onset and the first LTD payment — most commonly 119 or 120 days, aligning with the end of EI sickness benefits or an STD plan.

Check what actually covers the gap. A plan with a 120-day elimination period and no STD is asking employees to survive four months on EI or savings.

A file assembled to answer the own-occupation question, carried forward unchanged into the any-occupation period.

See the change-of-definition explainer. This is the most predictable and most preventable failure in the whole process.

Medical underwriting on an individual — required above the NEM, for late applicants, and for optional coverage.

Track outstanding forms. An unapproved form means the coverage does not exist, and the employer usually believes it does.

How long the insurer expects the claim to run, drawn from actuarial tables and adjusted for diagnosis, age, occupation and the contract’s definition of disability.

Duration assumptions are where reserves are most sensitive. A change in expected duration moves the reserve far more than a change in the monthly benefit amount.

Pricing built from the group’s own claims history, divided by the target loss ratio to find the premium needed to break even.

Powerful evidence that your current insurer has been over-charging. Much weaker as a tool for winning a better quote elsewhere, because a new insurer barely credits it.

The umbrella line covering everything medical that is not dental — drugs, paramedical practitioners, vision, medical equipment, hospital upgrades and out-of-country emergency care.

Usually the largest and most volatile line on a small plan, and where most of the design conversation happens.

Life and health insurance conduct of business guidance.

The conduct standard Ontario licensed advisers operate under.

The list of drugs the plan covers. An open formulary covers essentially anything with a DIN requiring a prescription. Managed or national formularies cover a curated list, generally excluding drugs with cheaper therapeutic equivalents.

Open to managed is a real saving and a real reduction in coverage. Any member currently on an excluded drug feels it immediately — never do it without an exception process in place.

A line, or an entire small group, rated purely on the insurer’s book with no experience component. Common for life, AD&D and dependent life, and for health and dental below a size floor.

If your plan is fully pooled, showing your experience report to an underwriter changes nothing about the quote. Use it to understand what you are buying, not to negotiate.

Specific, documented statements of what the person can and cannot do — concentration, task duration, interpersonal demand, pace, reliability — rather than a description of symptoms.

This is the translation step most files skip. Symptoms describe the condition. Restrictions and limitations describe the capacity, and the contract pays on capacity.

The documented statement of what a person can and cannot do — concentration, task duration, interpersonal demand, pace and reliability — graded against recognised assessment protocols rather than described in narrative.

This is the single most important document on a mental-health file. Symptoms describe the condition; restrictions and limitations describe capacity, and the contract pays on capacity.

Selecting and placing coverage with an appropriate insurer, and advising on the structure of the plan.

The visible part of the role, and the smallest part of the work.

Coverage granted without individual medical evidence up to a limit, because the group’s structure already prevents anti-selection — everyone eligible participates and nobody picks their own amount.

The core value of group insurance and worth saying out loud. An employee who could not buy individual coverage at any price is fully insured under a group plan. That is not a discount, it is access.

Your plan and experience are read the way an underwriter reads them, then compared against pricing across the Canadian market. Every result is reviewed by a licensed LLQP advisor before it reaches you.

The analysis is a starting point for a conversation with a licensed advisor, not a substitute for one.

Savings depend on how your plan is currently priced relative to its own claims experience, your group’s demographics, and how long it has been since the plan was last marketed.

A target of up to 15% on core lines is typical, not guaranteed, and subject to underwriting. A plan that has been marketed recently has less room than one sold once and never revisited.

Canada Employee Benefits Outlook.

Annual market outlook on benefits cost and design trends.

The broker currently servicing the plan.

Insurers usually notify the incumbent and allow a window to respond. Expect a call, and expect an offer. That is normal and not a reason to reverse course.

The reserve inside the incurred figure covering claims that have occurred but not yet arrived, set from the insurer’s own lag studies.

On a young plan, IBNR pushes incurred above paid. As the plan matures the reserve releases and incurred falls below paid. Both are normal; a wild swing between them deserves a question.

What the period actually cost: paid claims, minus payments made this period that belong to a prior one, plus a reserve for claims that happened in the period but have not been submitted.

The number underwriters rate on and the number you argue with. When a renewal letter and an experience report disagree, it is almost always because one quotes paid and the other incurred.

An examination by a clinician independent of both the claimant and the treating team, producing findings on function.

Can be requested by either side and cuts both ways. Useful where the treating documentation is thin; risky where it is strong and consistent.

An examination by a clinician independent of both the claimant and the treating team, producing findings on function rather than on diagnosis.

Cuts both ways. Valuable where treating documentation is thin; risky where it is strong, consistent and already functional in nature.

An agreement among most Canadian insurers, administered through the Canadian Drug Insurance Pooling Corporation, that shares recurring high-cost drug claims across participating insurers rather than leaving them with one. It exists so that small fully insured groups remain insurable and are not refused renewal over a single member’s medication.

Applies to fully insured groups under a size threshold that varies by insurer and band, so confirm rather than assume. Two consequences: a small plan with a catastrophic drug claimant is still marketable, and an insurer declining to quote purely on that basis is worth challenging.

The insurer’s threshold above which an individual’s claims in a year are removed from the group’s experience. It scales with group size — smaller group, lower threshold, more protection, higher pooling charge.

Always ask the pooling level when comparing quotes. A cheaper rate with a higher pooling threshold is not cheaper; it is risk handed back to you that surfaces in your next bad year.

Someone enrolling after their eligibility window closes — typically subject to medical evidence, and often restricted on dental for a period.

Enrolment deadlines are worth policing. A member who declines and later wants in has genuinely lost something, and the employer is usually blamed for it.

Individual claims are unpredictable; large numbers of them are not. An insurer cannot say whether you will claim, but across a hundred thousand people they can say what proportion will.

Every difference between how a nine-life group and a nine-hundred-life group is treated traces back to this one idea.

Advice across all lines, not only the ones with the largest premium.

Disability and life are where the advice gap is widest, because the premium is smallest and the consequences largest.

Incurred claims divided by premium. Of every dollar in, how many cents went back out as benefits.

Confirm which one you are reading. The incurred loss ratio is the meaningful figure; a paid loss ratio on the same group in the same year can differ by twenty points.

The plan reimburses at the price of the lowest-cost interchangeable generic regardless of what was dispensed, unless a prescriber documents a medical reason.

Standard on modern plans and rarely contentious. If a small plan lacks it, that is free money sitting on the table.

Pricing built from the insurer’s book of business — expected cost by age, gender, coverage tier, province and industry, grossed up for expenses.

This is what a competing insurer will mostly use on a small group. It is why your census, not your claims history, decides the number that comes back.

The Wellness Report.

Carrier-published workforce health research.

Taking a plan’s specifications to multiple insurers for competing quotes.

Deciding not to market is a legitimate outcome. A plan marketed into an unfavourable window can come back worse, and that costs more than it saves.

Coverage changes behaviour. A plan reimbursing 100% invites more use than one reimbursing 80% — not because people are dishonest, but because price no longer restrains anything.

The economic case for co-insurance, and the honest way to explain why a 100% plan costs what it does. Utilisation is not fraud; it is a predictable response to a price of zero.

Functional restoration and conditioning aimed at rebuilding capacity against specific job demands.

Most useful where the barrier is physical capacity rather than diagnosis.

Psychological assessment and treatment, occupational therapy, physical and active rehabilitation, and vocational services under one roof.

The default where a file has more than one barrier and nobody is coordinating them.

Federal legislation establishing first-phase public drug coverage in defined therapeutic areas, implemented through agreements with individual provinces.

Coverage and timing vary by province and are changing. Treat it as something to check the current state of before advising, not something to assert from memory.

A takeover provision under which the incoming insurer matches the prior plan’s treatment of members already disabled or absent — no coverage lost on the move, and none gained.

Ask for it in writing on any move involving anyone off work. Without it, an employee on leave can fall between two insurers with neither accepting responsibility.

The amount of coverage issued automatically without medical evidence. Above it, the member must complete individual underwriting.

The NEM scales with group size, so a small plan’s is low. Check the benefit formula against actual salaries: a formula that exceeds the NEM leaves your highest-paid people uninsured above it until they submit evidence, and almost nobody does unprompted. This is one of the most common uncovered exposures in small-group plans.

Standardised instruments, specialist assessment, or a psychological evaluation providing findings beyond self-report.

Not always available and not always necessary — but a file with none of it is asking the adjudicator to decide on narrative alone.

How other income reduces the LTD benefit. Primary direct offsets deduct the member’s own CPP-D award only; primary and dependant offsets also deduct children’s benefits.

A materially different outcome for a claimant with children, and almost never compared between quotes.

Provincial health insurance covers physician and hospital care. It does not cover outpatient prescription drugs for most working-age adults, dental, vision, or paramedical services — which is precisely the space private group plans fill.

Worth stating plainly to employers who assume Canada has universal healthcare in the fullest sense. The benefits plan exists because the public plan deliberately stops where it does.

Public drug coverage for Ontarians 65 and over and for certain other groups, including recipients of social assistance and home care.

A plan’s drug costs typically fall as members reach 65, because ODB becomes the first payer. Relevant when interpreting a plan with an ageing workforce.

Ontario applies 8% retail sales tax to group insurance premiums, including health and dental, and to the funding of self-insured arrangements.

It sits on top of the quoted rate. When comparing a quote to an invoice, one includes tax and one does not — confirm which before concluding anything about price.

Emergency medical care while travelling, subject to a trip-duration limit and often to stability requirements for pre-existing conditions.

Trip-duration limits catch people out constantly — snowbirds and long-stay travellers exceed them without realising. Worth flagging to staff once a year.

The ceiling on coverage regardless of formula or evidence.

Relevant when an owner-manager on a high salary assumes two times earnings means two times earnings. It may not.

The definition of disability. Own occupation pays if the member cannot do their own job. Any occupation pays only if they cannot do any job they are reasonably suited to. Most contracts run own-occupation for the first two years, then switch.

The change-of-definition date is where claims most often terminate — and it is rarely explained to anyone in advance.

Money the insurer actually disbursed during the period. A cash-flow number.

The wrong number to rate on. A crown done in April and submitted in July lands in next year’s paid claims even though the risk belonged to this year.

The annual limit for practitioner services — physiotherapy, massage, psychology, chiropractic — set per practitioner type or as a combined pool.

A per-practitioner limit is far richer than a combined one at the same headline number, since it can be claimed several times over. Check the structure before calling two plans equivalent.

The minimum share of eligible employees who must enrol. Where the employer pays the premium, participation is normally mandatory and 100%.

Watch waivers. Employees declining because of spousal coverage are usually permitted; too many waivers on any other basis can breach the contract and jeopardise the plan.

Real-time adjudication at the pharmacy counter, as opposed to pay-and-submit reimbursement.

Members judge the entire plan by whether the card works at the till. The most visible service feature you can change, and worth weighting heavily when choosing between insurers.

Total cost divided by covered employees per month — the metric used to compare plans of different sizes.

Only meaningful alongside the tier mix. A single-heavy group always looks cheaper PEPM than a family-heavy one on identical coverage. That is demographics, not value.

The higher your personal marginal rate, the more expensive the personal route becomes and the larger the HSA advantage.

The difference between a 43% and a 30% bracket is substantial on the same spend.

Setting maximums, co-insurance, eligibility and benefit formulas against budget and workforce.

Where most of the durable value sits, and the part most often left untouched for years.

The premium loading that funds the pool. Sits inside retention and rises as the pooling threshold falls.

On a small plan this can be a meaningful slice of retention. It is also the most defensible line in it — arguing it down means accepting more catastrophic exposure.

On small groups, disability reserves are frequently pooled rather than charged fully to the group’s own experience.

Ask explicitly how disability is treated on your plan. If it is pooled, a claim will not hit your renewal the way you fear. If it is not, one claim can dominate several years of experience.

Excludes disability arising from a condition treated in a defined window before coverage began — commonly three months prior, with the exclusion lapsing after twelve months of continuous coverage.

The single biggest risk in moving a plan’s disability line. If someone is under treatment at the switch, a new insurer may decline a claim the previous one would have paid. Check before any move, every time.

What the plan sponsor pays the insurer for the year. Cash in.

Check whether a figure is gross or net of tax. A billing statement usually shows premium plus Ontario RST; an experience report almost always shows premium before tax. Comparing one to the other invents an 8% gap that does not exist.

A tax levied on insurers on premiums written, in the order of 2% in Ontario. Embedded in the rate rather than shown separately.

Part of why retention never drops below a floor, and a useful answer when asked why an insurer cannot simply cut expenses further.

Future payments discounted back to today’s dollars using an assumed interest rate.

A falling discount rate raises reserves across an insurer’s whole block, independent of anything happening on your plan.

High-cost drugs require clinical approval before reimbursement. Step therapy requires a cheaper first-line therapy to be tried and shown ineffective first.

These are what make an open formulary affordable on a small plan. An insurer quoting an open formulary without them will price it accordingly.

How each line is priced. Health and dental are normally rated per single and per family unit per month; life and AD&D per $1,000 of volume; LTD per $100 of monthly covered earnings.

Because health and dental are priced per unit, an employee moving from single to family coverage raises cost immediately, mid-year, with no rate change at all.

The period the quoted rates hold — normally twelve months, occasionally fifteen to twenty-four on a takeover as an inducement.

A long guarantee is real value, but it is bought and priced into the rate. A twenty-four month guarantee against a twelve month one is not a like-for-like comparison.

How often the plan pays for a dental cleaning and examination — every six, nine or twelve months.

Stretching recall from six to nine months is one of the least-noticed dental savings available, and it does not reduce anyone’s maximum.

Under refund accounting, surplus belongs in some measure to the plan sponsor and can be returned or reserved. Under non-refund — sometimes called fully pooled — the insurer keeps the upside and absorbs the downside.

Almost every very small group is non-refund. Worth saying plainly: a good claims year does not earn a cheque, it earns a better argument at renewal.

Local physiotherapy and active rehabilitation for musculoskeletal claims.

Access and proximity matter more than brand on these files — a nearby provider attended consistently beats a better one attended sporadically.

Challenging the insurer’s annual rate action against the plan’s own experience.

Only possible if someone has actually read the experience report. Many renewals are passed on unexamined.

What happens when a claim closes earlier than assumed — the unused portion of the reserve is released back and improves the plan’s experience.

This is the mechanism behind return-to-work economics. Closing a claim early does not just stop payments; it releases the reserve behind them, which is a much larger number.

Intensive residential treatment where outpatient care has not been sufficient.

High cost against a single file, and frequently low cost against the reserve behind it.

Limitations written in the abstract rather than against the actual demands of the person’s job or, after the change of definition, against work generally.

The restriction needs to connect to a demand. Not simply that sitting is limited, but for how long, how it was assessed, and what that means for the specific duties in question.

Everything that is not claims: administration, claims adjudication, broker commission, pooling charges, premium tax, risk margin and profit.

This is the part of the premium a broker can actually influence, because broker commission sits inside it. On a small plan where every insurer’s rate is within a few points, it is often the most controllable lever available.

The window after termination during which the prior insurer continues to pay claims incurred while their contract was in force — often ninety days for submission.

Tell members explicitly where to send claims from the weeks either side of a change. This is where the complaints come from on an otherwise clean transition.

Income replacement for the first weeks of disability, typically a percentage of salary for fifteen to seventeen weeks, bridging to long-term disability.

Many small employers skip STD and rely on EI sickness benefits. That is a legitimate choice, but it should be a choice — most have never been shown what the gap looks like.

A request that a file be reviewed by the insurer’s dedicated mental-health resource rather than by a generalist adjudicator.

Frequently available and frequently not offered unless someone asks for it by name.

A request that the file be reviewed by the insurer’s internal mental-health resource rather than a generalist adjudicator.

Often the fastest meaningful step, and frequently not offered unless asked for.

Work absence rates and the Labour Force Survey.

The authoritative source for absence and labour market context.

The self-funded equivalent of pooling: insurance a self-insured plan buys to cap its exposure, either per individual or across the whole plan.

If self-funding is ever proposed to you, stop-loss is not optional. Self-funding claims without it is one catastrophic case away from a crisis.

The insurer’s break-even line — the share of premium they expect to pay out in claims. The remainder is retention.

Under target, your plan is profitable to the insurer and you have a case for a decrease. Over target, they are losing money and will come for it. A 72% target implies 28% retention, which is competitive for a small group; many sit at 30–40%.

If the employer pays the LTD premium, the benefit is taxable income to the employee. If the employee pays it, the benefit is received tax-free.

The highest-value piece of advice on this page, and it costs the employer nothing. Structuring LTD as employee-paid turns a taxable benefit into a tax-free one. If your employer pays your LTD premium, that is worth a conversation.

Federally, employer-paid health and dental premiums are not a taxable benefit to the employee. Employer-paid life, AD&D and critical illness premiums are. Employer-paid LTD premium is not itself taxed but makes the eventual benefit taxable. Quebec taxes health and dental premiums provincially.

The standard efficient structure is employer-paid health and dental, employee-paid LTD. It costs the employer nothing and materially improves what a disabled employee receives.

The age coverage ends — historically 65, increasingly 70 or on retirement.

With people working later, an employer with a hard 65 termination on life and LTD has an exposure they have almost certainly never considered.

Three owners, one Ontario corporation.

The arithmetic works for a single owner too; the combined totals simply scale.

A record of active treatment, adherence, changes in approach, and how the person responded to each.

An unexplained gap in treatment is read as improvement. Waitlists, cost barriers and referral delays are legitimate — they simply have to appear in the record at the time, not be reconstructed afterwards.

Expected inflation in claims cost — drug pricing, dental fee guide increases, utilisation creep, and the group ageing a year — applied to the manual side of the blend annually regardless of how the group performed.

This is the honest answer when someone asks why their rates rose in a year nobody claimed. A well-performing group rarely sees a flat renewal because trend never stops.

Assistance for Ontario households whose prescription drug costs are high relative to household income, after an income-based deductible.

A route worth knowing for a member facing catastrophic drug costs, even where the private plan responds. It exists for exactly the situations people assume have no answer.

Remote assessment and treatment, plus independent diagnostic services.

Solves the access problem that causes most documented treatment gaps outside major centres.

Transferable skills analysis, retraining and job search support.

Becomes central at the change-of-definition date, when the question moves from own occupation to any occupation.

The total amount of insurance in force on a line, in dollars. Life and AD&D are quoted per $1,000 of monthly volume; long-term disability per $100 of monthly covered earnings.

Salaries are not optional detail on these lines — they are the rating basis. Without them no insurer can produce a life or LTD number at all.

Service required before coverage begins — commonly three months.

In a high-turnover business, genuine cost control. In a nine-person office, mostly administrative noise and a gap in a new hire’s first months.

Life coverage continues without premium while the member is totally disabled, subject to approval.

Frequently missed on small plans. Employers keep paying life premium for a disabled employee for years because nobody filed the waiver.

Ontario coverage for work-related injury and illness, funded by employer premiums and entirely separate from the group plan.

Group plans exclude what WSIB covers. Disputes about whether an injury was work-related are therefore disputes about which system pays, and can leave a claimant temporarily with neither.