The Dental Hygienist's Wrists

First 24 months - own occupation. Most own-occupation definitions ask whether the insured is unable to perform the substantial and material duties of her own occupation. Nadia's own occupation is hands-on clinical hygiene: scaling, probing, sustained grip and repetitive wrist movement. Rheumatoid arthritis affecting both hands meets that test. She is entitled to the $4,200 monthly benefit, subject to the coordination clause and the 90-day elimination period.

The wrist/thumb exclusion does not apply. It is a diagnosis-and-treatment rider aimed at the de Quervain's, and rheumatoid arthritis is a separate systemic condition diagnosed after the policy was issued. The insurer may try to argue the wrist symptoms are continuous with the excluded condition; medical records showing the inflammatory markers, the bilateral presentation and the date of diagnosis are the answer. The 24-month exclusion period has also largely run by the time of any dispute.

After 24 months - any occupation. The definition typically shifts to any occupation for which she is reasonably fitted by education, training or experience, considering age and retraining potential. This is where claims are won and lost. The evidence that matters is not the diagnosis but the occupational analysis: a physical demands analysis of the hygiene role, a functional capacity evaluation, an ergonomic assessment, her transferable skills (charting, appointment management, patient education, sales roles in dental supply), labour market evidence for those roles at her wage level, and whether retraining is reasonable at 40.

An insurer will send a vocational rehabilitation consultant. Nadia should engage with retraining rather than refuse it; refusal, without medical justification, is a standard ground for terminating benefits.

Pre-disability monthly earnings: $78,000 ÷ 12 = $6,500.

85% cap: $6,500 × 0.85 = $5,525.

Offsettable income during total disability:

• Group LTD: 60% × $6,500 = $3,900
• CPP disability: $1,600
• Total offsets: $5,500

Individual benefit payable: $5,525 − $5,500 = $25 a month.

So a policy with a $4,200 face amount and a premium priced accordingly delivers $25 a month while she is totally disabled and receiving group LTD and CPP. The result is not an insurer error; it is the arithmetic of stacking an individual contract on top of a group plan that already replaces 60%, plus a CPP award.

Two further points follow.

First, the clause may also specify how offsets are calculated and what happens when a CPP award is retroactive or appealed. Many contracts apply the offset from the date CPP is approved, not the date it is paid, producing an overpayment the insurer will recover from future benefits. Nadia should expect a retroactive adjustment.

Second, this is a suitability failure at the point of sale, not a claims story. The advisor knew the group plan existed, did not model the 85% cap with a realistic CPP amount, and sold a benefit that was largely illusory. Under the fair treatment of customers standard, the file should show a documented offset comparison and an explanation that the policy's real value is in the gaps - a longer own-occupation period, a residual/partial disability benefit, or coverage if she changes to a job without group benefits.

Most individual disability contracts contain a residual or partial disability provision, distinct from total disability. It typically pays a proportionate benefit - the percentage loss of income, sometimes with a minimum threshold such as 20% - when the insured is working but earning less because of the condition, and it frequently requires rehabilitation or a return-to-work plan.

Her situation triggers two clauses to examine closely:

1. The partial disability definition and its waiting period. Some contracts require the partial benefit to follow a period of total disability, and some impose a separate elimination period for partial claims.
2. The recurrent disability clause. If she stops working again from the same or a related cause within a defined window (commonly six months) of returning, the second absence is treated as a continuation of the first, so a new elimination period is not served. Outside that window, she starts over.

Practically, Marie-Claire should: obtain the actual contract wording rather than the marketing summary; calculate the earnings loss for the three-day week; confirm with the group carrier and CPP how part-time earnings affect those benefits (CPP has its own rules on working while receiving a disability pension); and warn Nadia that a failed return to work documented as a refusal of suitable modified duties can be used against the claim.

The honest advice is uncomfortable: her individual policy will contribute very little while group LTD and CPP are in pay, and the file should say so plainly now. If the group coverage ends - she changes employers, or the plan is wound up - the individual policy becomes the primary source and the offset arithmetic changes completely. That is the scenario her $4,200 benefit is actually insuring.