LTD Benefits Cut Off After a Functional Capacity Evaluation

A long FCE can be compressed into two or three sentences in a termination letter. That compression is where nuance is easily lost.

Read the referral question first. Was the evaluator asked about general physical ability, a particular job, restrictions, tolerances or return-to-work capacity? A report is most useful when it is read within the purpose of the assessment.

Then check what the evaluator had in front of them. Recent medical information? Specialist or rehabilitation reports? A real description of your job? A job description can be technically accurate and still miss the part of the work that causes the problem.

Do not jump to the last page. Look at the activities, duration, repetitions, symptoms, changes during testing and anything that was not completed. Note what the protocol did not assess as well. An FCE has a defined scope. Knowing where that scope ends is part of reading it properly. The companion guide, Functional Capacity Evaluations in LTD Claims: What the Test Measures and What to Expect, goes deeper on the assessment itself.

Now compare the report with the insurer's letter. If the evaluator recorded limits or qualifications, are they still there? If the report answered a narrow functional question, what supports the broader conclusion that you can work? In some files, that bridge is obvious. In others, the termination letter reaches further than the report seems to go. A report can be accurate within its limits and still be used too broadly.

Real jobs combine demands. Some are physical. Others involve concentration, deadlines, interruptions, driving, pace, decision-making, safety requirements or limited control over breaks. Hours and frequency matter too.

The occupational information deserves the same care as the testing itself. Was the evaluator looking at your actual work, an employer description or a generic occupation? Two people can have the same job title and very different schedules, travel, lifting, productivity expectations and freedom to change position. The Canadian Centre for Occupational Health and Safety's Job Demands Analysis guidance describes job demands as including physical, cognitive and environmental demands.

The Supreme Court of Canada's decision in Paul Revere Life Insurance Co. v. Sucharov is important here: the policy wording governs, and the ability to perform individual duties does not by itself settle whether the regular occupation can be performed as a whole.

A termination letter can make a complicated file look simple. When it does, follow the decision backward.

1. Start with the policy. What disability definition applies on the termination date? LTD policies differ, and some change the occupational test after a defined period. A decision near that transition may be answering a different question from the one considered earlier in the claim. If the timing is close to a definition change, read 24-Month LTD Change of Definition in BC.
2. Then look at the occupation. If the insurer says you can return to your own work, is that work described accurately? If another occupation is proposed, what are its actual duties and what assumptions were made about your qualifications?
3. Finally, look beyond the FCE. Medical reviews, rehabilitation records, surveillance, vocational evidence and other assessments may all have influenced the decision. If the letter relies on several sources, read them as one argument. Do they fit together?

Conflicting evidence has no automatic ranking order. A treating doctor may be addressing diagnosis, treatment and function over time; an FCE evaluator may be answering a narrower functional question. Look for whether the insurer dealt with the conflict or simply quoted the evidence that pointed one way. For a deeper review of work-focused medical and functional proof, see LTD Medical Evidence in BC.

If benefits were being paid and are now being stopped, something changed in the insurer's analysis. Find that hinge.

The change could be genuine improvement, new medical evidence, rehabilitation progress, the FCE itself, new occupational information or a vocational opinion. The policy may also have moved to a different disability definition. Sometimes the facts look much the same; what changed is the insurer's interpretation of them.

A long letter can hide a short reason. A termination decision may turn on one or two newer points even after pages of claim history. Once you identify them, you can see whether the dispute is really medical, occupational, contractual, factual or some combination of them.

Fidler v. Sun Life Assurance Co. of Canada was a British Columbia group LTD case decided by the Supreme Court of Canada. It was not an FCE case, but it remains useful for one reason: an adverse decision has to be read against the evidentiary record as a whole.

When benefits stop, the urge to answer immediately is understandable. Resist the urge to write a long response before you know exactly what you are responding to.

Read across the documents. Words such as "capacity," "sedentary," "restrictions" and "return to work" can sound precise while carrying different meanings in different reports. Trace the important words back to their source. If you cannot see how one step leads to the next, that gap matters.

Legal advice becomes especially useful when the file stops making sense on its face. That can happen when:

• the termination letter sounds more definite than the FCE;
• the occupation used in the analysis does not resemble the work that appears relevant under the policy;
• an important area of function was outside the assessment;
• the FCE and treating evidence point in materially different directions;
• several assessments or vocational opinions have been combined in a way that is difficult to follow;
• the disability definition changed or another occupation is being proposed; or
• the timing or next procedural step is unclear.

A careful review can confirm that the insurer has substantial evidence, identify an incomplete occupational comparison, or show that the conclusion reaches beyond the underlying record. Any of those outcomes is useful because it tells you what, if anything, needs a response.

That clarity keeps the response aimed at the real problem. More medical records will not fix a bad job description. A long account of how difficult the FCE felt may not answer a policy-definition issue. Before adding more paper to the file, know what needs to be answered.