Reporting Your Disability Claim/FMLA

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1 Reporting Your Disability Claim/FMLA The Cooper Standard Short-Term Disability Policy and Family & Medical Leave Policy are administered by Liberty Life Assurance Company of Boston, a member of the Liberty Mutual Group. Liberty is available 24 hours a day, 7 days a week and offers employees direct access to claims/leave resources and information. You can easily report a claim/leave and check its status through Liberty s dedicated secure website or by telephone. Please visit to access employee resources and online tools, as referenced below. When Do I Report a Disability Claim or Family & Medical Leave? Your own serious illness, disability, or maternity leave: You may report a claim up to 30 days in advance of a planned disability absence OR as soon as you are aware that you will be disabled due to illness or injury for more than 5 business days. Your family member s serious illness, military leave, or your own intermittent leave: You may report a leave when you will be out of work for 3 consecutive days or intermittently to care for an immediate family member suffering a serious illness or to care for a newborn, foster or adopted child. How Do I Report a Disability Claim or Family & Medical Leave? 1. Contact your HR Representative to report your absence. 2. Print this document, sign and date the Authorization to Release Information section below, and leave with your physician or medical care provider at your next visit. Note: Liberty requires your physician to provide information about your medical condition. If this information cannot be obtained, benefits may be delayed. 3. Report your claim/leave via First time users must register using Company Code cooperstandard. Please have the following information available when you report your claim/leave: Your physician or medical care provider s name, address, fax and telephone numbers Your HR Representative s name, telephone number and address Reason you are out of work (diagnosis/symptoms) Your last day worked, first day absent from work, and anticipated return to work date Or you can call and speak with an Intake Specialist to report your claim/leave. 4. Keep a record of your claim/leave number. Reporting your claim/leave online provides the added convenience of printing a report which includes your claim/leave number and a summary of your claim/leave details. 5. You may securely check the status of your claim/leave online at or by calling your Case Manager at or Family & Medical Leave Specialist at Authorization to Release Information I authorize any health care provider having information about my physical or mental condition and treatment to give all information to the Company in the Liberty Mutual Group of companies and/or Plan Sponsor to which I am submitting a claim. I understand the information obtained by this Authorization will be used to determine eligibility for benefits. Information obtained under this Authorization or directly from me may be released to persons/organizations providing medical treatment or claim management/advisory services in connection with my claim, including Employee Assistance Programs (EAP), or other similar disease management/assistance programs providing services to the Plan Sponsor and/or the Company. This Authorization is valid for two years from the date appearing below with my signature. I have the right to revoke this Authorization by notifying the Company. I know that I may request a copy of the Authorization and I agree that a photographic copy shall be as valid as the original. Employee Signature Date Print Employee Name Group products and services are offered by Liberty Life Assurance Company of Boston, a member of Liberty Mutual Group.

2 Frequently Asked Questions for Leave Administration Q: How does the leave administration process work? A: Cooper Standard has partnered with Liberty Mutual Insurance (Liberty) to administer Short Term Disability (STD) and Family Medical Leave (FMLA). Once you report your disability claim, by following the instructions on the Reporting Your Disability Claim/FMLA, you will be assigned a disability case manager (DCM) who will call within two business days to discuss the details of why you are or plan to be out of work. Next, your DCM will contact the treating physician(s) related to your claim to obtain as much detailed medical information as they can over the phone. This may include such information as diagnosis, symptoms, verification of procedures/surgeries and treatment plan. Based on certain circumstances of your claim, other information may also be requested. A written request may need to be faxed for medical information from the treating physician(s), at which time you may be asked to supply a written authorization to those treating providers in order to secure outstanding information. Your employer may also be contacted to verify such things as job duties and hours worked. Q: How do you handle Early Submission Claims, or claims submitted prior to a date of disability? A: Your claim will remain in a pending status until Liberty is able to verify the event that caused your disability has occurred (such as surgery or birth (delivery) of a child.) Once your date of disability arrives, Liberty will reach out to your providers via phone to verify the event that caused your disability has occurred and update your status to approved once Liberty has verified the event has taken place. Your claim may be denied in the event that your scheduled absence is cancelled or postponed for an extended period of time. Q: Who should I contact at Liberty? A: When you have an approved Short Term Disability claim, with or without an approved corresponding FMLA leave, the DCM should be your main point of contact. If you have an approved FMLA leave with no corresponding approved Short Term Disability claim, your leave specialist should be your main point of contact. If you attempt to call your assigned DCM or Leave Specialist and reach their voic , you can leave a message, or you can press 0 and be directed to another member of the team who will be able to assist you. Q: What happens if my treating physician(s) will not provide medical information over the phone? A: Even though disability claims are not subject to HIPPA regulations, every treating physician has their own policy regarding the release of medical information. Your DCM will do their best to confirm and gather information over the phone in order to make a decision on your claim. In the event your treating physician(s) will not release information to us over the phone, or additional information is needed, your DCM will fax a request to the physician(s) office. Once the request for medical information has been sent,

3 you will receive a letter from your DCM notifying you of our request(s) and when that information is due. Lack of sufficient medical documentation can result in interruption of your pay and/or a denial of STD benefits. Q: What type of medical information will be requested from the treating physician(s)? A: Liberty will request confirmation of delivery, surgery, type of procedure and in some circumstances Liberty will need to obtain copies of your medical records, office visit notes, treatment plan and test results (if applicable) for the conditions preventing you from being able to work. Additionally, if necessary Liberty may request that your doctor completes forms detailing your medical condition and restrictions. Once the request for medical information has been sent you will be mailed a letter from your DCM notifying you of our request. Lack of sufficient medical documentation may result in interruption of your pay and/or a denial of STD benefits. In order to help expedite attaining the necessary medical information, Liberty Mutual asks that you: Provide all treating providers with a signed copy of the attached Authorization form. Advise your treating provider that you have filed for STD/leave and that Liberty will be contacting them to verify medical information Is there somebody specific that the case manager should reaching out to obtain the information (medical records, office manager, Release of Information, etc) Q: How often does my DCM follow up when information has been requested from treating physician(s)? A: After requesting medical information to make an initial determination from your treating providers, your DCM will follow up with you and your treating physician(s) via phone 15 days after the initial request was submitted to your providers for any outstanding medical records. If the information is not received within 30 days of the initial request, your claim may be denied for failure to provide proof of disability. Once sufficient documentation is received, your claim may be reopened. Q: How long will it take to obtain a decision on my claim? A: Typically, our initial determinations are made within 10 business days from when the claim is reported, provided Liberty has obtained all medical information. Depending on how timely Liberty receives your medical information and the complexity of your disability, this timeframe may be shortened or extended. To ensure a timely decision, it s important that you partner in the administration of the claims process to the extent that you can, including assisting the claims team in securing outstanding medical information from your providers as necessary, and as you are able to. Responding to an inquiry made to you directly from your DCM in a timely manner is essential to the ease of the administration of your claim. Your responsiveness to inquiries made to you directly from your DCM is very important. Q: How will I know that my claim is approved? A: Your DCM will call to inform you of the approval and will provide you with the date that your claim has been approved through and a letter will be sent to you. Q: When will I receive my benefit payment? A: You will receive your benefit payment from Cooper Standard through normal payroll. Your location HR Representative in charge of initiating your pay after receiving notification from Liberty Mutual that your claim has been approved and what your approved through date is. Delays in receipts of medical records/information could cause a delay in benefits.

4 Q: What is an elimination period? A: Depending on your employee group at Cooper Standard, you may be required to be disabled for a certain number of consecutive days before being eligible for benefits. The days included in the elimination period are not paid under the STD plan. This could be where Cooper talks about using vacation time for during the elimination period. Q: What happens if I need to be out of work longer than my initial approved through date? On or around your approved through date, your DCM will follow up with you to clarify your next steps. If you need to be out of work longer than the approved through date, additional medical information may be required to support any extension of the disability claim. Your DCM will send a request for medical records/information to support ongoing disability to all your treating providers. This information will be due within 15 days from the initial request. Your DCM will follow up with you and your treating physician(s) within 7 days. Q: What happens if my claim is denied? A: If a decision has been made to deny your claim, the DCM will call you to explain the reason for the claim denial and inform you of how to appeal this decision. A letter will be mailed to you detailing why your claim was denied and will also contain instructions on how to appeal that decision. Your first step to filing your appeal is to send it in writing to Liberty Mutual at: The Liberty Life Assurance Company of Boston Disability Claims P.O. Box 7206 London, KY A decision on your appeal can take up to 30 days depending on the time it takes to procure and review additional medical information. If your appeal is denied, a 2 nd level review will be conducted by the Cooper Standard Benefits Department. Q: What happens when I am released to return to work by my doctor? A: When your doctor indicates that you have a release to return to work date, you must notify both your DCM and your HR Representative. You must provide that note to your HR Representative only, prior to your return to work date. The note should indicate if you have been released to full duty or specifically list any restrictions you may have. Your DCM should be advised of any restrictions placed upon you by your treating provider to help determine if they can assist in facilitating a return to work. Once you have provided this note to your HR Representative, HR will communicate the authorization to return to work with any restrictions to your supervisor, if applicable. Q: What do I do if my STD claim has closed, but I still need to miss work intermittently for physical therapy, cancer treatments, follow up visits, etc.? A: If your short term disability claim has been closed but you still need to miss work from time to time due to such reasons as physical therapy, chemotherapy treatments, etc., you should call Liberty Mutual to report a new intermittent leave. These absences may qualify for job protection under FMLA and will need to be reported to Liberty Mutual. Once reported to Liberty Mutual, you will receive a letter with detailed

5 instructions on how to report any intermittent time that you have taken off of work due to your medical condition. Q: How long do I have to provide Liberty Mutual my completed Certification of Healthcare Provider form? A: If your leave is coordinated with Short Term Disability, the leave and the claim will remain coordinated for 30 days utilizing the claim as a replacement to approve the leave. If there is insufficient information received to approve the claim, at day 15, the leave and claim will separate. The claim will be reviewed to determine if there is sufficient information to approve the leave, if there is insufficient information to approve the leave, the FMLA only letter will be released and the employee will be provided the Certification of Healthcare Provider form and will have 15 days to provide the completed form. If completed forms are not received with in the 15 days the leave will be denied and the leave will remain in denied status. If your leave is not coordinated with Short Term Disability, you have 15 days from the date that the acknowledgement letter, with the required forms, is created in Liberty Mutual s system. If the forms are not received by the 15 th day your leave will be denied. You will then have 15 days to appeal the leave, by providing Liberty Mutual completed documentation. If documentation is not received with in the 15 day appeal period your leave will remain in denied status. Q: How do I report the time that I have missed from work due to my FMLA leave? A: If you are out on a continuous leave your time will automatically be deducted from your available FMLA entitlement based on the work schedule that is provided from your company. If you are taking time on an intermittent basis your time will need to be reported to Liberty by using the integrated voice response system to ensure you time is appropriately deducted from your available entitlement bank. You will receive an instruction sheet on how to use the IVR system along with your FMLA Acknowledgement letter.