DIOCESE OF METUCHEN OFFICE OF HUMAN RESOURCES TEMPORARY DISABILITY INSURANCE PROGRAM FOR LAY EMPLOYEES PLAN DOCUMENT Effective January 1, 2014 (Replaces January 1, 2013 Plan Dcument)
1 CONTENTS OVERVIEW... 2 FUNDING... 2 ELIGIBILITY... 2 EXCLUSIONS... 2 DEFINITION OF DISABILITY... 3 PREGNANCY RELATED DISABILITY... 3 WEEKLY BENEFIT RATE... 3 MAXIMUM BENEFIT AMOUNT (MBA)... 4 WAITING PERIOD... 4 FILING A CLAIM... 4 SUPPLEMENTAL BENEFITS COVERAGE... 5 ADMINISTRATION... 5 PARTICIPATION IN OTHER BENEFIT PROGRAMS... 6 FAMILY AND MEDICAL LEAVE... 6 DATE BENEFIT PAYMENTS END... 6
2 OVERVIEW The Dicese f Metuchen, by virtue f its status as a nt-fr-prfit church rganizatin, elects nt t participate in the New Jersey Temprary Disability Prgram. With very few exceptins, the majrity f ur affiliated parishes and schls likewise d nt participate in the state prgram. As an alternative, the Dicese f Metuchen has established a Temprary Disability Insurance (TDI) Plan fr lay emplyees in rder t prvide eligible emplyees with prtectin against wage lss shuld they becme disabled due t nn-wrk related illness r injury. Of curse, the Dicese is free t mdify r discntinue this plan at any time, withut cnsulting emplyees and withut ntice, except where prescribed by law. FUNDING Each parish is respnsible fr the payment f TDI benefits t its wn emplyees. Accrdingly, it is recmmended that an apprpriate reserve be set aside each year fr payments which might ccur under the prvisins f this plicy. Benefit payments are t be charged n Accunt 505-01 (Disability Insurance Expense). ELIGIBILITY In rder t be eligible fr benefits, an emplyee must meet ALL f the fllwing criteria: 1) Be regularly scheduled t wrk twenty (20) r mre hurs per week. 2) Have cmpleted six mnths f cntinuus emplyment. 3) Be actively emplyed n the date f his r her disability. 4) Be under the cntinuus care f a licensed health care prvider wh certifies that the emplyee is unable t perfrm his r her regular jb r any wrk apprpriate t the disability that may be ffered. 5) Prvide updated medical infrmatin n a regular basis as requested. EXCLUSIONS Cverage is NOT prvided fr the fllwing: 1) Disability fr which the emplyee is entitled t benefits under any Wrkers' Cmpensatin prgram, r which is caused by injury r illness resulting frm sme ther ccupatin. 2) Disability suffered because f an autmbile accident fr which the emplyee is entitled t benefits under any "n-fault" autmbile plicy. 3) Disability caused by willful, intentinal, self-inflicted injuries. 4) Disability suffered r caused by war r an act f war. 5) Disability acquired in the perpetratin f an illegal act. 6) If the emplyee is receiving Scial Security Disability Benefits.
3 DEFINITION OF DISABILITY Fr purpses f this prgram, disability means the inability f an individual t perfrm the regular r custmary wrk because f the individual's physical r mental cnditin. PREGNANCY RELATED DISABILITY The inability t wrk due t pregnancy and/r childbirth is treated as any ther disability under the Dicese f Metuchen s TDI Plan. Fr mst pregnancies, the disability perid begins tw weeks befre birth, and ends six weeks after birth (eight weeks after birth fr Caesarian sectin). WEEKLY BENEFIT RATE Under this prgram, an eligible emplyee is paid tw-thirds (2/3) f his/her average weekly wage up t the maximum amunt payable set fr that calendar year. The maximum weekly benefit rate (WBR), which crrespnds t the Maximum Rate established by the New Jersey State Plan, is $595 fr the 2014 calendar year. The weekly benefit rate is calculated using the emplyee s average weekly wage based n the earnings in the eight calendar weeks immediately befre the week in which the disability begins. The ttal wages earned during all base weeks wrked in the eight week perid are divided by the number f such base weeks t btain the average weekly wage (fr purpses f calculating the base wage rate, temprary disability payments received during the 52 week base year are NOT cnsidered wages, and therefre nt included). Example: An emplyee earned the fllwing weekly wage in the last eight weeks befre becming disabled: Week 1 -- $300 Week 5 -- $300 Week 2 -- $250 Week 6 -- $300 Week 3 -- $250 Week 7 -- $350 Week 4 -- $300 Week 8 -- $350 Ttal wages fr thse eight weeks = $2,400 The average weekly wage is $300 ($2,400 divided by 8 weeks) The Weekly Benefit Rate is 2/3 x $300 = $200
4 MAXIMUM BENEFIT AMOUNT (MBA) The maximum benefit amunt which may be paid under this prgram fr each perid f disability is ne-third (1/3) f the ttal wages the emplyee earned in cvered emplyment during the Base Year (52 calendar weeks immediately preceding the week in which the disability ccurred), r 26 times the weekly benefit amunt, whichever is less. Example: An emplyee has nly wrked 6 mnths and earned $17,000 during the Base Year, but has an average weekly wage f $675. The MBA is the lesser f: (a) 1/3 x $17,000 = $5,666 r (b) 26 x $450 = $11,700 Maximum Benefit Amunt in this example: $5,666.00 WAITING PERIOD Benefits are payable n the eighth cnsecutive calendar day f an emplyee s disability. The first seven days f disability are cnsidered the Waiting Perid. If an emplyee returns t wrk, but is absent within 14 calendar days r less due t the same medical cnditin, n waiting perid is required and the tw disabilities are cunted as ne cntinuus perid f disability, with a maximum benefit perid f 26 weeks. FILING A CLAIM It is the emplyee s respnsibility t file the necessary claim frms with his r her emplyer prmptly after being unable t wrk as a result f nnccupatinal illness r injury. All claims must be filed within thirty (30) days n the date the disability began. Failure t file a claim n time may result in benefits being denied r reduced. The required frms include an Emplyee Statement f Applicatin and a Medical Certificatin f Attending Physician, included in the Appendix f this
Plan Dcument. Claim frms may als be btained frm the n-site benefits crdinatr at the emplyee s lcatin, r by cntacting the Office f Human Resurces, Dicese f Metuchen, 146 Metlars Lane, Piscataway, NJ 08854. 5 SUPPLEMENTAL BENEFITS COVERAGE In additin t TDI benefits ffered under this prgram, the Dicese has secured supplemental cverage thrugh an independent insurance carrier. This supplemental cverage is intended t prvide equivalent incme prtectin t eligible emplyees whse annual earnings are abve a certain level, and whse benefit level wuld therwise be capped at the weekly maximum benefit under this plan. Eligibility fr benefits is determined by the insurance carrier and is subject t the terms and cnditins f the respective Plan Dcument fr the prgram. Infrmatin n the supplemental cverage, including instructins fr filing a claim, can be btained by cntacting the Office f Human Resurces, Dicese f Metuchen, 146 Metlars Lane, Piscataway, NJ 08854. ADMINISTRATION TDI Benefits shall be paid beginning the first day fllwing the eliminatin perid fr the duratin f the emplyee s disability, up t a maximum f twenty-six weeks. Benefit payments are subject t incme tax withhldings, including FICA withhldings. During the eliminatin perid, the emplyee is required t exhaust available sick days. In the event n paid sick days are available, the eliminatin perid shall be withut pay. The emplyee, at the discretin f the emplyer, may als supplement any accumulated paid leave fr TDI benefits. Substituting paid leave, hwever, shall nt increase the available TDI benefits beynd the 26 weeks. An emplyee may be required t submit t a physical examinatin by a physician appinted by the Dicese in rder t supprt his r her disability claim. In such instances, there shall be n cst t the emplyee. Failure t submit t an examinatin, hwever, may result in the denial f further benefits. In the event an emplyee desires t prtest a denial f benefit, he r she may request t have the circumstances cncerning such denial adjudicated by an ad hc cmmittee, which shall be appinted by the pastr. In a difficult r unusual situatin, the pastr may seek t cnsult with the dicesan Office f Human Resurces. Prir t returning t wrk, the emplyee will be required t furnish a certificatin frm a medical physician apprved by the Dicese, which authrizes his r her return t active wrk.
6 PARTICIPATION IN OTHER BENEFIT PROGRAMS While n TDI, the emplyer will maintain the emplyee s grup health, dental, LTD and life insurance cverage n the same terms as if he r she had cntinued t wrk, althugh the emplyee is required t pay his r her share f health insurance premiums. Fr purpses f the Lay Emplyee Retirement Plan, leave under the TDI plan shall be cunted twards the emplyee s hurs wrked. FAMILY AND MEDICAL LEAVE Under the Family and Medical Leave Act (FMLA), an emplyee may be entitled t take up t 12 weeks f jb-prtected leave in a 12-mnth perid (24-mnth perid fr NJ Leave Act) fr specified family and medical reasns. In accrdance with standard plicies f the Dicese, leave under the TDI Plan will generally be cunted twards the emplyee s rights under bth FMLA and NJFLA. DATE BENEFIT PAYMENTS END Disability payments will end n the earliest f: 1) The date n which the emplyee is n lnger disabled 2) The end f the Maximum Benefit Perid (26 weeks) 3) Upn payment f the Maximum Benefit Amunt (MBA) 4) The date n which an emplyee ceases r refuses t participate in a rehabilitatin prgram required by the emplyer 5) The date n which an emplyee fails t have a medical exam requested by the emplyer 6) The date n which an emplyee fails t prvide required prf f cntinuing disability 7) Upn death
Dicese f Metuchen APPLICATION FOR TEMPORARY DISABILITY BENEFITS PART A (TO BE COMPLETED BY THE CLAIMANT) TO BE CONSIDERED FOR TEMPORARY DISABILITY BENEFITS, THIS APPLICATION AND THE MEDICAL CERTIFICATE MUST BE RETURNED WITHIN 30 DAYS OF INJURY OR ILLNESS. SUBMIT THIS FORM TO YOUR LOCAL BENEFIT COORDINATOR. A COPY OF SHOULD ALSO BE SENT TO: OFFICE OF HUMAN RESOURCES DIOCESE OF METUCHEN 146 METLARS LANE PISCATAWAY, NJ 08854 OR BY FAX TO: (732) 562-2464 1. Last name: First: Middle: 2. Birth Date 3. Scial Security N. 4. Hme Address required (Street, Apt.#, City, State, Zip Cde) 5. Lcatin: 6. Occupatin: 7. What was the last day that yu actually wrked befre yur disability began? Mnth / Date / Year 8. The first day yu were unable t wrk due t present disability: (Include Saturday, Sunday, r Hliday) D nt list future dates. 9. If nw recvered, what was the date f the first day yu were able t resume wrk: (N future dating) 10. Was this injury/illness caused by yur jb? Yes N (This questin must be answered) If yes, date f wrk related injury/illness: Did yu ntify anyne that yu were injured? Yes N 11. Describe yur disability (hw, when, where it happened): 12. Identify the physician r hspital treating yu fr this disability: Name: Phne: Address: 13. Certificatin and Signature: I was unable t wrk during the perid fr which benefits are claimed and hereby certify that I have read and understand my benefit rights and respnsibilities. I am aware that if any f the freging statements made by me are knwn t be false, r I knwingly fail t disclse a material fact, I may be subject t penalties, which may include criminal prsecutin. I understand that I may be required t cnsent t the release f medical infrmatin fr the prcessing f my temprary disability benefits. Claimant s Signature: Date:
Dicese f Metuchen MEDICAL CERTIFICATION FOR TEMPORARY DISABILITY BENEFITS PART B (TO BE COMPLETED BY THE PHYSICIAN) T be cnsidered fr Temprary Disability Benefits, the Medical Certificate must be returned within 30 days f injury r illness. Please cmplete and submit t yur lcal Benefit Crdinatr. A cpy shuld als be faxed t the Office f Human Resurces, Dicese f Metuchen: (732) 562-2464 EMPLOYEE INFORMATION NAME: ADDRESS: T be cmpleted by Treating Physician: This infrmatin will be used t evaluate the patient s qualificatin fr disability benefits. Disability is based n 1) patient s inability t perfrm the essential functins f his/her jb; 2) diagnsis. (Please be sure t answer all questins.) 1. Patient has been under my care fr this perid f disability: Frm t Frequency f treatment: Patient was last treated by me n: 2. Date the patient was unable t perfrm his/her regular wrk due t this disability: 3. Estimated date patient will be able t return t wrk: 4. Is this cnditin the result f a wrk related injury r illness? Yes N 5. Diagnsis: (nature and cause f this disability which prevents patient frm wrking? 6. Surgery perfrmed: Yes Type f surgery: 7. Treatment: 8. If pregnancy, prvide estimated date f delivery: Cmplicatins, if any: 9. Date(s) f emergency rm care r hspitalizatin: Name and address f any specialist treating patient: I hereby certify that the abve statements, in my pinin, truly describe the claimant s disability and the estimated duratin theref. Upn request, I will prvide r be willing t discuss additinal medical infrmatin required by The Dicese f Metuchen fr the prcessing f the abve emplyee s temprary disability benefits. PHYSICIAN S NAME: PHYSICIAN S SIGNATURE: (stamp will nt be accepted) ADDRESS: PHONE NUMBER: