A 26-year-old woman fighting breast cancer was shocked to find she doesn't qualify for long-term disability payments, despite having disability insurance through her employer's group plan.
"I didn't think I was going to have to fight cancer — and then fight with this insurance company," said Katie Evans.
Evans is an administrator for several Shoppers Drug Mart stores in Ottawa. Her long-term disability (LTD) policy through Blue Cross Medavie became effective in December, three months before she was diagnosed with cancer.
"I didn't have to answer a [health] questionnaire," Evans said. "I filled in the form to confirm that I was covered for LTD and I signed it. Done."
However, the previous September — three months before that coverage kicked in — she had asked her doctor about a lump in her breast. At that time, after tests, a surgeon told her not to worry.
"She said the words 'you do not have cancer,'" said Evans.
In March, further tests brought the bad news that she had breast cancer and had to undergo a mastectomy and chemotherapy.
Earlier doctor visits cited
Her employer's insurance company then decided, because of that initial fall consultation, that the lump was a "pre-existing condition" and therefore she did not qualify for long-term disability coverage.
"I went through our employee handbook. I've gone through online what I have access to from the insurance company, and nowhere does it say anything about a pre-existing condition. I was blindsided."
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The denial letter sent to Evans from Blue Cross Medavie states that any treatment, including just filling a prescription, within six months before coverage starts can be evidence of a "pre-existing condition."
If the employee then makes a claim for a condition related to that — within the first two years of coverage — their claim will be denied.
According to insurance experts, millions of Canadians could face the same dilemma.
Industry figures show 9.6 million Canadians have long-term disability insurance through their employers, and estimates are about two-thirds of their policies have an "exclusion clause" for pre-existing conditions.
Blue Cross Medavie refused to discuss Evans' case, citing privacy. The industry association also declined a request for an interview, because it said it won't talk about specific cases.
"Provincial insurance law permits a pre-existing condition clause to be included in group insurance contracts and can apply for up to two years," reads an email from the Canadian Life and Health Insurance Association.
"After this period, an insurer cannot deny a claim based on the prior existence of a disease or physical condition."
"I'm 26. I don't have equity in anything. I don't have anything. I don't have savings," said Evans. "My landlord isn't going to say, 'You have cancer you don't have to pay rent.'"
Denials come as shock
A Vancouver lawyer who takes on cases against insurance companies believes almost all employees who pay into group disability insurance plans have no idea how limited the coverage is.
He said many are devastated to find they're not covered, when they find themselves struggling with illness or disability.
Stanley said when people like Evans contact him, he finds it "heartbreaking" to tell them they have no case, because the clauses are spelled out in the fine print.
"They are devastated to hear that they have no coverage. Often it means they lose their homes. They have to downsize. It affects them profoundly," said Stanley.
He pointed out that even an employee taking medication for high blood pressure, who then has a stroke when they are new to a job, could be denied disability coverage based on the "pre-existing" condition of high blood pressure.
"This exclusion is quite common, and it is quite broad," said Stanley.
In Evans' case, she is facing more surgery and several more weeks of recovery before she can return to work.
"I am absolutely exhausted," said Evans. "I don't think my employer would appreciate me sleeping at my desk.
"I don't want to risk getting sick and then have to be off again in a few weeks for a couple more months or put myself in the hospital."
Employer stepping in
Meanwhile, as a result of CBC News inquires, Shoppers Drug Mart has now decided to dip into a charitable fund, through its "Shoppers Drug Mart WOMEN" health program, to give Evans direct financial support while she recovers.
She said corporate headquarters is not responsible for the particular disability insurance plan Evans has, because she works for an associate owner (franchisee) who chose the plan.
An employee of any company who is unhappy with their group coverage can purchase extra insurance for long-term disability on their own, said broker Glenn Cooke of Insurecan.
But the premiums can reach several hundred dollars a month, which is unaffordable for most people, he said.
"Go to your employer [instead] and tell them what you need, and get a better designed plan," advised Cooke.
Stanley gave similar advice.
"People really need to be aware of what they are getting from their group plan. If they are not happy with it, they need to raise a stink, and talk to their administrators and their employers about it," he said.
Evans is concerned people might postpone going to the doctor or getting treatment until their insurance coverage is in place.
"The message, that I don't agree with, is don't tell any doctors. Don't let anybody know. Make sure that you keep this to yourself," said Evans.
"You couldn't pay me any amount of money to let the cancer spread."