A claim form is necessary to apply for benefits with a medical determination provided by a licensed practitioner.
Applying for Disability
A covered employee may apply for disability benefits when they are unable to work as a result of a medical illness or injury.
A claim form, Preliminary Statement of Disability, is available in the location human resources office. The “Employee Section” must be completed fully by the employee and signed. The “Employer’s Section” must be completed by the District Human Resources office. The attending physician must complete the back of form “Attending Practitioner’s Statement” and sign.
When the employee and the attending physician has completed the form, the form is forwarded to the location human resources office. The location forwards the form to the District Human Resources office with applicable leave forms for processing.
The district office completes the “Employer’s Section”, attaching copies of the leave form, generates the employee’s job description and mails the materials to the insurance carrier for review and/or approval.
The insurance carrier will correspond with the employee by mail upon receipt of the claim forms and documentation. The District office will receive copies of all correspondence.
Carrier Review of the Claim Form
The insurance carrier will review the claim form in accordance to the attending practitioner statement. The attending practitioner defines the period of total disability and the degree of the disability. If the practitioner does not provide enough medical information for the insurance to make a decision concerning the approval of the claim, the physician is contacted for more medical information. Obtaining more medical information may include the employee, and all physicians and/or hospitals that have treated the employee for the disability related illness. This action may delay a determination for benefits and cause the employee to have a financial hardship. Employees are encouraged to notify their physicians when additional information is requested to speed the process.
The carrier will determine any other benefits amounts of entitlement such as social security, workers compensation, or retirement benefits.
If the claim is approved, the claim is paid as a monthly benefit. If the claim is denied, the carrier will notify the employee by mail and copy District Human Resources office and the location.
Approval of STD Claim
If the claim is approved by the carrier, short term disability benefits will be paid after the 30-calendar day elimination period and when all paid sick leave has been exhausted. Short Term disability benefits are paid for a maximum period of five (5) months.
The short term disability benefit check is forwarded to the District Human Resources office for distribution by mail to the employee. A copy of the check is filed in the employee’s disability file (separate from the employee’s personnel file) and a copy is sent to the location human resources office.
In order to calculate the beginning date of your benefits from the insurance carrier, see the following example:
Example (contains no leave integration): The physician certifies the first day of total disability as March 3 and does not determine when you may be able to return to work. The carrier would start your 30-calendar day elimination period on March 3. The elimination period would be over on April 1. The payment period begins April 2. The payment ending date would May 1. The check would cover from April 2 to May 1 – 30 days, or to day you returned to work, whichever comes first.
Approval of LTD Claim
If the claim is approved by the Carrier, long term disability benefits will be paid after the 90-calendar day elimination period and when all sick leave has been exhausted. Long-term Disability maximum benefits are paid dependent upon the age of the employee when they become totally disabled. If under age 60, pays until age 65, if over age 60, pays for 5 years or to age 70 or to 12 months whichever is greater.
The maximum benefit for nervous and mental conditions is 24-months, no matter what age of disability.
The long term disability check is forwarded to the employee’s home address. A copy of the check is not kept on file at the District or location human resources office.
In order to calculate the beginning date of the benefits for the insurance carrier, see the following example:
Example (contains no leave integration): The physician certifies the first day of total disability as March 3rd and does not determine when you may be able to return to work. The carrier would start your 90-calendar day elimination period on March 3. The elimination period would be over on July 4. The payment period begins on July 5. The payment ending date would be August 5. The check would cover from July 5 to August 5 – 30 days, or the day you returned to work, whichever comes first.
Coordination of STD and LTD
At a point defined by the carrier, long term disability benefits can be collected with short-term disability benefits. The same claim form will be used to determine short and long term disability benefits. These benefits may be combined for a period of two months or less, dependence upon your first day of total disability. When these benefits are combined, they pay at 70 percent.
Appealing the Denial of a Claim
If the claim is denied, the employee may appeal the decision by making a written request for reconsideration with additional medical information.
If the claim is denied a second time, the employee may file a grievance with the Employees Retirement System along with copies of the insurance’s correspondence. The request must be within 90 days of the denial. ERS will send the employee a decision in writing.