SHORT TERM DISABILITY CLAIM

Transcription

1 Packet Instructions AIG Life Insurance Company* Wilmington, Delaware Delaware American Life Insurance Company* Wilmington, Delaware Member companies of American International Group, Inc. Administrative Office: 3600 Route 66, Neptune, NJ SHORT TERM DISABILITY CLAIM *This company does not solicit business in New York. This packet contains the forms necessary to apply for Disability benefits. For specific information about your Disability insurance coverage, refer to your group insurance certificate. The certificates are the ultimate authority for Disability claim decisions. If you need other information, please contact your employer s benefit administrator. EMPLOYEE INSTRUCTIONS: 1. Complete and sign your portion of the claim form. 2. Your treating physician should complete the Attending Physician s Statement. If more than one physician is treating you for your disabling condition, each should complete a form. Additional forms are available from your employer s benefit administrator. 3. Sign and date the Authorization and Fraud Statement, and send them, along with the Employee s Statement, to the AIG Claims Processing Center listed below. 4. Maintain a copy of all documents for your records. EMPLOYER INSTRUCTIONS: * 1. Complete and sign your portion of the claim form. 2. Attach a copy of job description and payroll records for the 3 months preceding disability. 3. Submit all forms along with required documents to the AIG Claims Processing Center listed below. 4. Notify the AIG Claims Processing Center listed below of the employee s return to work date. * If your Policy Number begins with a V, attach a copy of the employee s Enrollment/Application form. MAIL CLAIM TO AIG CLAIMS PROCESSING CENTER: Disability Insurance Specialists (DIS) P.O. Box 25 Bloomfield, CT (800) (860) FAX OTHER BENEFITS THAT MAY REDUCE YOUR DISABILITY BENEFITS Other benefits you receive may reduce the amount of Disability benefits due you. Your group insurance certificate lists these benefits, which may include, but are not limited to, sick leave, Workers Compensation, State Disability, Social Security, and Retirement. To avoid a possible overpayment of your claim, please inform us if you receive these or other benefits. WHEN YOU RETURN TO WORK Your Disability benefits usually stop when you return to work. Be sure that you or your employer notify us immediately when you plan to, or have, returned to work to assure no overpayment occurs. All portions of this form packet must be completed to avoid undue delay in processing the claimant s request for benefits.

2 Short Term Disability Benefits: Employee s Statement Mail to AIG Claims Processing Center: Disability Insurance Specialists (DIS) P.O. Box 25 Bloomfield, CT AS REQUIRED BY LAW, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR A STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIALLY THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME. TO BE COMPLETED BY THE EMPLOYEE PLEASE TYPE OR PRINT BE SURE TO ANSWER ALL QUESTIONS - FAILURE TO DO SO MAY DELAY YOUR CLAIM First Name Last Name Social Security Number Address City State Zip Code Phone Number of Birth Height Weight Gender Occupation Female Male I have been unable to work because of this condition I returned to work on a part time basis on since I returned to work on a full time basis on of your injury or the date you first noticed the symptoms of your illness Is your injury or illness related to your occupation? If yes, explain Yes No Describe how and where the injury occurred or describe the first symptoms of your illness List name and address of your family physician you were first treated for your illness or injury Treated by: Hospital: Doctor: Have you ever had the same or similar condition in the past? Yes No If yes, when? Treated by: Hospital: Doctor: How does your condition prevent you from working? Pregnancy: Expected delivery date: Actual delivery date: Type of delivery: Normal C-Section Have you applied for or are you currently receiving benefits from: Applied Yes No Receiving Yes No Applied For Amount Received Weekly Monthly Effective / End Social Security Workers Compensation State Disability Insurance Retirement or Pension (Employer, PERS, STRS, PERA, etc.) Please specify type FMLA Other (e.g. unemployment or union benefits, etc.)

3 EDUCATION LEVEL Yes No If no, last grade attended. Grade School Graduate High School Graduate GED College Graduate Degree Major Post Graduate Degree Major Have you attended, or are you currently attending any trade schools or received other special training? Yes No If yes, please describe. WORK EXPERIENCE (Complete the following starting with your most recent work experience.) 1. Job Title & Employer of Employment Duties Last Salary From: To: 2. From: To: 3. From: To: ACKNOWLEDGEMENT I hereby certify that the answers I have made to the foregoing questions are both complete and true to the best of my knowledge and belief. I acknowledge that I have read the applicable Fraud Statement included with this form. Signature

4 Short Term Disability Benefits: Employer s Statement Mail to AIG Claims Processing Center: Disability Insurance Specialists (DIS) P.O. Box 25 Bloomfield, CT AS REQUIRED BY LAW, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR A STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIALLY THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME. TO BE COMPLETED BY THE EMPLOYER Employee's Name Social Security Number Policy Number Insurance Class Employee's Of Hire Employee's Original Effective Employee's Effective With Us Occupation At Time Of Disability (Attach Copy Of Job Description) Last Day Worked Reason For Stopping Work Returned To Work On Full Time Part Time ( hours/week) Employee's Earnings:$ (Check one) hourly weekly monthly annual commission other Attach payroll records for the 3 months preceding disability. Was salary continued beyond last day worked? Yes No Has the employee applied for or is he/she receiving benefits from: Social Security Workers Compensation State Disability Insurance Retirement or Pension (Employer, PERS, STRS, PERA, etc.) Please specify type Applied Yes No Receiving Yes No FMLA Work Status When Disability Began Full Time Part Time ( hours/week) If Yes, Weekly Amount $ Applied For Paid Through Amount Received Weekly Monthly Effective / End Other (e.g. unemployment or union benefits, etc.) Name and address of Workers Compensation carrier Workers Compensation claim number List any other source of income to which the employee is entitled as a result of this disability Percentage of employee contribution towards disability premium (see Internal Revenue Code Section 105(a) and Regulations thereunder) % Was employee s job primarily sedentary or did it involve considerable physical activity In a work day given two breaks and a meal break, the employee must Lift (in pounds) Carry (in pounds) Reach above shoulder Never Occasionally Frequently Climb Never Occasionally Frequently Crawl Never Occasionally Frequently Bend/stoop: Never Occasionally Frequently Employer Employee s contributions were made on Pre tax basis Post tax basis Premium paid through date Total Hours With positional change Sit (hrs) Stand (hrs) Walk (hrs) Alternately sit/stand (hrs) Division Address Telephone Number Fax Number ACKNOWLEDGEMENT I hereby certify that the answers I have made to the foregoing questions are both complete and true to the best of my knowledge and belief. I acknowledge that I have read the fraud notice included on this form. Authorized Representative Print Signature Title address

5 Attending Physician s Statement Mail to AIG Claims Processing Center: Disability Insurance Specialists (DIS) P.O. Box 25 Bloomfield, CT TO BE COMPLETED BY THE EMPLOYEE First Name Last Name Employer Policy Number TO BE COMPLETED BY THE ATTENDING PHYSICIAN Is there a current signed HIPAA Authorization to Release Information on file? Yes No Diagnosis ICD-9 Classification Symptoms Height Weight B/P PREGNANCY (if applicable) Expected date of delivery Actual date of delivery Type of delivery Normal C-section Significant complications, if any HISTORY the patient ceased working When did symptoms first appear or injury happen? Has the patient ever had the same or similar condition? Yes No If yes, when? Is this condition related to the patient s employment? Yes No of first visit (s) of subsequent visits Did you complete a Workers Compensation claim form? Yes No of most recent visit Planned course and duration of treatment (include surgery and medications, if any) HOSPITALIZATION (if applicable) admitted Reason discharged Name and address of hospital In a work day given two breaks and a meal break, your patient is able to Total Hours With positional change Lift (in pounds) Carry (in pounds) Sit (hrs) Stand (hrs) Walk (hrs) Reach above shoulder Never Occasionally Frequently Alternately sit/stand (hrs) Climb Never Occasionally Frequently Crawl Never Occasionally Frequently Bend/stoop: Never Occasionally Frequently PHYSICAL IMPAIRMENT (*As defined in Federal Dictionary of Occupational Titles) Class 1 No limitation of functional capacity; capable of heavy work* no restrictions (0-10%) Class 2 Medium manual activity* (15-30%) Class 3 Slight limitation of functional capacity; capable of light work* (35-55%) Class 4 Moderate limitation of functional capacity; capable of clerical/administrative (sedentary) activity* (60-70%) Class 5 Severe limitation of functional capacity; incapable of minimal (sedentary) activity* (75-100%) Remarks

6 MENTAL/NERVOUS IMPAIRMENT (if applicable) (a) Please define stress as it applies to this patient. (b) What effect has stress and, or problems in interpersonal relations had on the patient s ability to perform her/his job functions, if any? Class 1 Patient is able to function under stress and engage in interpersonal relations (no limitations) Class 2 Patient is able to function in most stress situations and engage in most interpersonal relations (slight limitations) Class 3 Patient is able to engage only in limited stress situations and engage in only limited interpersonal relations (moderate limitations) Class 4 Patient is not able to engage in stress situations or engage in interpersonal relations (marked limitations) Class 5 Patient has significant loss of psychological, physiological, personal and social adjustment (severe limitations) Remarks Most recent GAF Score of assessment Do you believe the patient is competent to endorse checks and direct the use of proceeds thereof? Yes No PROGNOSIS Since onset of symptoms, the patient s condition has Improved Not changed Retrogressed When do you anticipate the patient can return to work? Unable to determine, follow up in: Weeks Never REHABILITATION (a) Is patient a suitable candidate for further rehabilitation services?... Yes No If yes, explain under remarks. (i.e., cardiopulmonary program, speech therapy, etc.) (b) Would job modification enable patient to work with impairment?... Yes No If yes, explain under remarks. PATIENT S JOB: ANY OTHER WORK: (c) When could trial employment commence?... Full-time Part-time Full-time Part-time / / / / Mo. Day Year Mo. Day Year (d) Would vocational counseling and/or retraining be recommended?... Yes No If yes, explain under remarks. Are you aware of any other disability income policies?... Yes No Insurance company name(s) Policy number(s) REMARKS OTHER TREATING PHYSICIANS OR CONSULTANTS Physician Name Specialty Phone Number AS REQUIRED BY LAW, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR A STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIALLY THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME. PHYSICIAN INFORMATION (Please type or print) Name of physician completing this form Phone Number Specialty Tax ID Number Fax Number Address City State Zip Code ACKNOWLEDGEMENT I hereby certify that the answers I have made to the foregoing questions are both complete and true to the best of my knowledge and belief. I acknowledge that I have read the fraud notice included on this form: Signature

7 Fraud Statement With the exception of any source(s) of income reported on this form, I certify by my signature that I have not and am not eligible to receive any source of income, except for my AIG American General Disability Income. Further, I understand that should I receive income of any kind or perform work of any kind during any period AIG American General has approved my disability claim, I must report all details to AIG American General immediately. If I receive disability income benefits greater than those which should have been paid, I understand that I will be required to provide a lump sum repayment to the insurance company. The insurance company has the option to reduce or eliminate future disability payments in order to recover any overpayment balance that is not reimbursed. For residents of all states EXCEPT California, Florida, New Jersey, Colorado, Pennsylvania, Arkansas, New Mexico and Virginia: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall be subject to a substantial civil penalty where and to the extent of the law. For residents of Florida: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree. For residents of New Jersey, Arkansas and New Mexico: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties. Any person who includes any false or misleading information on an application for insurance policy is subject to criminal and civil penalties. For Residents of Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an Insurance Company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or it s agent who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to an insurance settlement or award shall be reported to the Colorado Division of Insurance. For residents of Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects a person to criminal and civil penalties. For residents of California: For your protection, California law requires the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. The information contained in the Short Term Disability Benefits statement is true and complete to the best of my knowledge and belief. X Signature of the Employee X

8 Authorization for Release of Information Claimant's Name of Birth Social Security Number I AUTHORIZE THESE PERSONS having any records or knowledge of me or my health: Any Physician, Medical Professional, or Health Care Provider Any Hospital, Clinic, Pharmacy, or any other Any Employer, Business Associate Medical Care Institution Group Policyholder, Contract Holder, Vendor, Health Any Insurer Benefit Plan Administrator or their successors Any State Vocational Rehabilitation agency Any Governmental Agency (including and not limited to the and other providers of Rehabilitation Services Social Security Administration, Veterans Administration, The Medical Information Bureau (MIB), Railroad Retirement Board and the Jones Act Administration) any Consumer Reporting Agency, Financial Any Prepaid Health Plans Institution or Company which collects health and insurance claim information TO PROVIDE: Medical and nonmedical information that they may have concerning my health condition, or health history, or regarding any advice, care or treatment provided to me. This information and/or records may include, but is not limited to: Charts, notes, x-rays, operative reports, laboratory and medication records and all other medical information about me, including medical history, diagnosis, testing, test results, prognosis and treatment of any physical or mental condition, including: Any disorder of the immune system, including HIV, Acquired Immune Deficiency Syndrome (AIDS) or other related syndromes or complexes. Any communicable disease or disorder. Any psychiatric or psychological condition, including test results, psychotherapy notes, diagnosis summary, functional status, treatment plan, symptoms, prognosis and progress to date. Any condition, treatment, or therapy related to substance abuse, including alcohol and drugs. and: Any non-medical information requested about me, including such things as education, employment history, earnings or finances, or eligibility for other benefits (for example, Social Security Administration, Public Retirement Systems, Railroad Retirement Board, claims status, benefit amounts and effective dates, etc.). TO AIG AMERICAN GENERAL, ITS SUBSIDIARIES AND AFFILIATES, including, but not limited to Disability Insurance Specialists, and any other person or firm performing business or legal services on their behalf. I acknowledge that any agreements I have made to restrict my protected health information do not apply to this authorization and I instruct the persons and organizations identified above to release and disclose my entire medical record without restriction. I understand that AIG American General will use the information to determine my eligibility or entitlement for insurance benefits. I understand and agree that this authorization shall remain in force throughout the duration of my claim for benefits with AIG American General. I understand that I have the right to refuse to sign this authorization and a right to revoke this authorization at any time by sending a written statement to AIG American General, except to the extent it has been relied upon to disclose requested records. A revocation of the authorization, or the failure to sign the authorization, may impair AIG American General ability to evaluate or process my claim and may be a basis for denying my claim for benefits. I understand that in the course of conducting its business, AIG American General may disclose to other parties information it has about me. AIG American General may release this information about me to a reinsurer, a plan administrator, or any person performing business or legal services for AIG American General in connection with my claim. I understand that AIG American General complies with state and federal laws and regulations enacted to protect my privacy. I also understand that the information disclosed to AIG American General pursuant to this authorization may be subject to redisclosure with my authorization or as otherwise permitted or required by law. (Disability coverage is not subject to the Privacy Rules of the Health Insurance Portability and Accountability Act (HIPAA) and therefore the release of information to AIG American General is not protected under the Act.) I acknowledge that I have read this authorization and the state variations (if applicable) included in this packet. A photocopy or facsimile of this authorization is as valid as the original and will be provided to me upon request. Name Signature of Claimant/Guardian/Representative