Short-Term Disability

Transcription

1 Effective January 1, 2012 Short-Term Disability Experis Policy Number: GP CONSULTANT SHORT TERM DISABILITY PLAN 1

2 Short-Term Disability (STD) How Your Short Term Disability Coverage Works...3 How You Enroll for STD Benefits...3 What is a Disability...4 How B e n e f i t s a r e P a i d...4 Medical Documentation Successive Periods of Disability...5 Coordinating With Other Income Benefits...5 How You Submit A Claim...6 Appeals of Adverse Determination...7 Exclusions and Limitations...9 Recovery of Overpayments...9 Return to Work Please consult the Administrative Overview section for additional information. CONSULTANT SHORT TERM DISABILITY PLAN 2

3 Benefits Short-Term Disability Plan (STD) Disability coverage is designed to replace a portion of your income if you are unable to work because of your own illness or injury. Eligibility You are eligible to enroll in the Consultant STD Plan if you are an active employee of Experis. Active employees are: Employees that are paid an average of 30 hours per week (based on the hours you were paid in the previous month), and Work for Experis. How You Enroll for STD Benefits STD is an optional benefit, so you must enroll for it during your initial eligibility period. You choose the weekly benefit that provides the income replacement that you need. Your weekly amount choices are dependent on your annual salary at the time of your enrollment in the plan. Weekly benefits are available in the amounts of $300, $500, $750, $1,000, $1,250 or $1,500. You may enroll for the benefit during your initial eligibility period. If you do, your STD benefits become effective six months after your date of hire. During the first six months of coverage, disabling injuries or illnesses that occurred during the three months prior to the effective date of coverage are excluded. If you enroll for the STD plan after you are initially eligible to enroll, you must provide evidence of good health that is satisfactory to Aetna. This will apply if you request to enroll more than 31 days after your initial eligibility date or your request to reinstate coverage that ended because you voluntarily stopped your coverage or you didn t make the required contributions. How Your Short-Term Disability Coverage Works The Short-Term Disability (STD) Plan provides total or partial income replacement if you are sick or injured (on or off the job), and are unable to work. To receive disability benefits, you must be an eligible employee and under the care of a qualified physician. Your STD Plan is administered by Aetna who determines entitlement and authorizes all benefit payments. You are eligible for STD benefits if you are disabled and unable to work because of an illness that is not an occupational illness, an injury that is not an occupational illness, or a disabling pregnancy-related condition, while covered under this plan. Disabled means you are unable to perform the material and substantial duties of your regular occupation and you have a 20% or more loss in your weekly earnings while under the continuous care of a health care professional. Benefits start on the 15 th calendar day for a disability due to illness, a disabling pregnancy-related condition or injury. STD benefits are payable for up to a maximum of 24 weeks, subject to approval. CONSULTANT SHORT TERM DISABILITY PLAN 3

4 What is a Disability? For STD purposes, you are considered disabled when Aetna determines that: You are unable to perform the material and substantial duties of your regular occupation due to your sickness or injury; and You are under the regular care of a doctor, and You have a 20% or more loss in your weekly earnings due to that sickness or injury. Medical documentation supports your disability; and Aetna can verify your disability. You must be under the regular and continuous care of a physician and follow a prescribed course of treatment. For disabilities relating to an injury or a physical illness or condition, an approved physician is defined as a person who is performing tasks that are within the limits of his or her medical license; and Is licensed to practice medicine and prescribe and administer drugs or to perform surgery; or Has a doctoral degree in Psychology (Ph.D or Psy.D) whose primary practice is treating patients; or Is a legally qualified medical practitioner according to the laws and regulations of the governing jurisdiction. For disabilities relating to a mental illness or condition, a determination of disability will be based on medical information submitted that supports your not being able to perform the duties of your job. How Benefits are Paid If you qualify for STD benefits, you will receive the weekly benefit amount that you selected when you enrolled in the plan. You are deemed to be disabled if you are unable to perform the material and substantial duties of your regular occupation and you have a 20% or more loss in your weekly earnings while under the continuous care of a health care professional. Your benefit will be paid by Aetna. Benefits start on the 15 th calendar day for a disability due to illness, a disabling pregnancy-related condition or injury. The maximum period for payments is 24 weeks. Medical Documentation Aetna must receive objective medical evidence that supports the disability before your STD claim can be approved. This information is required when you make your STD claim and periodically thereafter. Objective medical evidence includes, but is not limited to: Data and records from your attending physician; CONSULTANT SHORT TERM DISABILITY PLAN 4

5 Narrative reports; X-ray and laboratory findings; and Consulting physician reports. Successive Periods of Disability If you recover and return to work after receiving STD benefits and then become disabled again, the manner in which the second period of disability is treated depends on when you became disabled again and the cause of the second disability. If your disability recurs from the same or related cause fifteen or more consecutive days after you return to work, you will be required to satisfy a new fourteen day waiting period if approved for STD. If your disability is due to the same or related illness, injury or pregnancy related condition and separated by less than 15 days in a row of active work, it will be treated as the same disability and in this case you will not need to meet a second fourteen day elimination period. Coordinating With Other Income Benefits When calculating the benefit payable to you, other income benefits that you, your spouse, our children or dependents are eligible for because of your disability or retirement are taken into consideration. Any weekly benefit payable to you by Aetna will be reduced by other income benefits. Your STD benefit is reduced by the amount of any: Unemployment compensation benefits Workers Compensation No-Fault Auto Laws for Loss of Income Benefits under the Federal Social Security Act, Railroad Retirement Act, Canada Pension Plan and Quebec Pension Plan Disability or unemployment benefits payable by either insured or uninsured plans as a result of employment by or association with your employer or any group, association, union or other group Veteran s Benefits State Disability Payments* 401(k) Elected Benefits Sick or Vacation pay that the company pays to you Other income you are paid because of your disability Retirement benefits *If you work in a state with state provided disability benefits, it is your responsibility to apply for t h o s e state provided disability benefits as the benefits of this plan will automatically be offset from your STD benefit. CONSULTANT SHORT TERM DISABILITY PLAN 5

6 How You Submit a claim for STD Benefits If you are absent from work due to an illness or injury for a period that is expected to last more than three consecutive days, you must: Notify your supervisor or manager Contact Aetna to file a STD claim if you expect to be absent from work for a period of five or more days. You may contact Aetna within 30 days in advance for an anticipated disability. If you are unable to contact Aetna, your spouse, family member or your manager can contact Aetna to start a claim on your behalf Apply for state disability benefits, if applicable Maintain contact with A e t n a and your supervisor or manager should your condition change or continue beyond the approved benefit period Note: You may also qualify for a leave of absence under the Family and Medical Leave Act of 1993 (FMLA). If you do, your STD and FMLA will run concurrently. Submit a Claim You are required to submit a claim to Aetna in writing. Claim forms may be obtained from Aetna. You must provide true and correct information that Aetna requests. At any time, Aetna may require copies of documents to support your claim including data about employment. You must also provide Aetna with authorizations to allow them to investigate your claim and eligibility for and the amount of work earnings and other income benefits. The deadline for filing a STD claim is 31 days after the end of the fourteen day elimination period. If, through no fault of your own, you are not able to meet the deadline for filing a claim, your claim will still be accepted if you file as soon as possible. Unless you are legally incapacitated, late claims will not be covered if they are filed more than one year after the deadline. Payment of a Claim Benefits will be paid as soon as the necessary proof to support the claim is received by Aetna. STD benefits will be paid weekly, at the end of each week during the period for which benefits are payable. Weekly benefits for a period of less than a week will be prorated. This will be done on the basis of the ratio to 7 days of the day of eligibility for benefits during the week. Aetna shall notify you of the claim determination within 45 days of the receipt of your claim. This period may be extended by 30 days if such an extension is necessary due to the matters beyond the control of the plan. A written notice of the extension, the reason for the extension and the date by which the plan expects to decide your claim, shall be furnished to you within the initial 45-day period. This period may be extended for an additional 30 days beyond the original 30-day extension if necessary due to matters beyond the control of the plan. A written notice of the extension, the reason for the extension and the date by which the plan expects to decide your claim, shall be furnished to you within the first 30-day extension period if an additional extension of time is needed. CONSULTANT SHORT TERM DISABILITY PLAN 6

7 However, if a period of time is extended due to your failure to submit information necessary to decide the claim, the period for making the benefit determination by Aetna will be tolled (i.e., suspended) from the date on which the notification of the extension is sent to you until the date on which you respond to the request for additional information. If your claim is denied, in whole or in part, you and your authorized representative will receive a written notice from Aetna of your denial. The notice will be written in a manner calculated to be understood by you and shall include: a) The specific reason(s) for the denial, b) References to the specific plan provisions on which the benefit determination was based, c) A description of any additional material or information necessary for you to perfect a claim and an explanation of why such information is necessary, d) A description of Aetna s appeals procedures and applicable time limits, including a statement of your right to being a civil action under section 502(a) of the Employee Retirement Income Security Act of 1974 (ERISA) following your appeals, and e) If an adverse benefit determination is based on a medical necessary or experimental treatment or similar exclusion or limit, an explanation of the scientific or clinical judgment for the determination will be provided free of charge upon request. Appeals of Adverse Determination If your claim for benefits is denied or if you do not receive a response to your claim within the appropriate time frame (in which case the claim for benefits is deemed to have been denied), you or your representative may appeal your denied claim in writing to Aetna within 180 days of the receipt of the written notice of denial or 180 days from the date such claim is deemed denied. You may submit with your appeal any written comments, documents, records and any other information relating to your claim. Upon your request, you will also have access to, and the right to obtain copies of, all documents, records and information relevant to your claim free of charge. A full review of the information in the claim file and any new information submitted to support the appeal will be conducted by Aetna, utilizing individuals not involved in the initial benefit determination. This review will not afford any reference to the initial benefit determination. Aetna shall make a determination on your claim appeal within 45 days of the receipt of your appeal request. This period may be extended by up to an additional 45 days if Aetna determines that special circumstances require an extension of time. A written notice of the extension, the reason for the extension and the date that Aetna expects to render a decision shall be furnished to you within the initial 45-day period. However, if a period of time is extended due to your failure to submit information necessary to decide the appeal, the period for making the benefit determination will be tolled (i.e., suspended) from the date on which the notification of the extension is sent to you until the date on which you respond to the request CONSULTANT SHORT TERM DISABILITY PLAN 7

8 for additional information. If the claim on appeal is denied in whole or in part, you will receive a written notification from Aetna of the denial. The notice will be written in a manner calculated to be understood by the applicant and shall include: a) The specific reason(s) for the adverse determination, b) References to the specific plan provisions on which the determination was based, c) A statement that you are entitled to receive upon request and free of charge reasonable access to, and make copies of, all records, documents and other information relevant to your benefit claim upon request, d) A description of Aetna s review procedures and applicable time limits, e) A statement that you have the right to obtain upon request and free of charge, a copy of internal rules or guidelines relied upon in making this determination, and f) A statement describing any appeals procedures offered by the plan, and your right to bring a civil suit under ERISA. If a decision on appeal is not furnished to you within the time frames mentioned above, the claim shall be deemed denied on appeal. If the appeal of your benefit claim is denied or if you do not receive a response to your appeal within the appropriate time frame (in which case the appeal is deemed to have been denied), you or your representative may make a second, voluntary appeal of your denial in writing to Aetna within 180 days of the receipt of the written notice of denial or 180 days from the date such claim is deemed denied. You may submit with your second appeal any written comments, documents, records and any other information relating to your claim. Upon your request, you will also have access to, and the right to obtain copies of, all documents, records and information relevant to your claim free of charge. Aetna shall make a determination on your second claim appeal within 45 days of the receipt of your appeal request. This period may be extended by up to an additional 45 days if Aetna determines that special circumstances require an extension of time. A written notice of the extension, the reason for the extension and the date by which Aetna expects to render a decision shall be furnished to you within the initial 45-day period. However, if a period of time is extended due to your failure to submit information necessary to decide the appeal, the period for making the benefit determination will be tolled from the date on which the notification of the extension is sent to you until the date on which you respond to the request for additional information. Your decision to submit a benefit dispute to this voluntary second level of appeal has no effect on your right to any other benefits under this plan. If you elect to initiate a lawsuit without submitting a second level or appeal, the plan waives any right to assert that you failed to exhaust administrative remedies. If you elect to submit the dispute to the second level of appeal, the plan agrees that any statute of limitations or other defense based on timeliness is tolled during the time that the appeal is pending. CONSULTANT SHORT TERM DISABILITY PLAN 8

9 Benefits If the claim on appeal is denied in whole or in part for a second time, you will receive a written notification from Aetna of the denial. The notice will be written in a manner calculated to be understood by the applicant and shall include the same information that was included in the first adverse determination letter. If a decision on appeal is not furnished to you within the time frames mentioned above, the claim shall be deemed denied on appeal. Exclusions and Limitations STD coverage does not cover any disability on any day that you are confined in a penal or correctional institution for conviction of a criminal act or other public offense. You will not be considered disabled and no benefits will be payable in that situation. Additionally, you are not eligible for STD benefits for any disability that: Is due to an occupational illness or occupational injury Active participation in a riot or civil commotion Is due to intentionally self-inflicted injury (while sane or insane) Is due to war, whether declared or undeclared Results from your commission or attempting to commit a felony Results from a motor vehicle accident caused by operating a vehicle while voluntarily under the influence of alcohol. Recovery of Overpayments If the STD benefit for any week is overpaid, Aetna has the right to recover the amount overpaid by either: Deducting the overpayment from any future payments Requiring a lump sum repayment from you in the overpaid amount Return to Work In order to return to work after your illness or injury, you must obtain a Fitness-for- Duty statement from your doctor. The statement must detail the medical restrictions, if any. This statement must be provided both to Aetna and your manager prior to returning to work. Questions If you have questions, comments or concerns about your benefits or coverage, or if you are required to submit information to Aetna, you may contact Aetna s Home Office at: Aetna Life Insurance Company 151 Farmington Avenue Hartford, CT CONSULTANT SHORT TERM DISABILITY PLAN 9