Ongoing Disability Claim Process

What to expect from us once a disability claim is submitted

As the manager of an employee who has filed a disability claim, you may be contacted by the employee's claim manager after the disability claim has been submitted. In straightforward cases, such as uncomplicated maternity claims, this may not be necessary.

What the claim manager will need from you once a claim is submitted

The claim manager will confirm the date of the employee's first day of absence from work with you, ask about the employee's job duties, and discuss general issues about the employee's return to work.

The claim manager will want to know if you can accommodate the employee's return to work on a part-time, work-at-home, or modified-duty basis, and will also ask if there are alternative jobs available that the employee can do.

What to do while waiting for a claim decision to be made

The period of time during which a claim is being reviewed and investigated before a determination is made is called the "claim pending" stage. During this stage, there is nothing for you as the manager to do except continue weekly "check-ins" with the employee.

Process for when a disability claim is approved, but additional medical information is needed

In this case, the disability claim has been approved, but no firm return-to-work (RTW) date or length of disability has been established. In many cases, the approval letter has an "approved through" date, which is the duration for which the disability has been approved. It is usually based on the employee's medical treatment.

The "approved through" date does not necessarily mean that the employee will return to work on that date. If the disability is extended, another approval letter will be sent updating the next "approved through" date.  

• The claim manager will send an approval letter to the employee with the "approved through" date.
• You should continue communication with the employee and discuss potential RTW options.
• If you have any questions (e.g., about changes of approved-through dates) or status requests, you can call or email the claim manager.
  
  

Process for when a disability claim is denied

A claim may be denied if the employee is not eligible, if the employee does not meet the definition of disability in your employer's benefits contract, if the condition the employee has is not covered by the disability benefit contract, or if the medical information supports a determination that the employee is able to work. This list is not all-inclusive—other exclusions may apply, depending on your benefit plan.

If the employee's claim is denied, your Human Resources manager and the employee will be informed of the decision by the claim manager. If your employee has been notified that his or her request for disability benefits was denied, he or she now has 180 days to appeal this denial. This amount of time for appeal is required by federal regulations (if the plan is covered under the Employee Retirement Income Security Act of 1974, or ERISA).

Process to appeal a disability claim denial

If the employee chooses to appeal the decision on the disability claim, the employee can refer back to the letter outlining the reason for the decision. This letter will provide the employee guidance on what additional information can be submitted and where the information should be sent.

Considerations to be aware of if the disability claim is denied

A claim that has been denied may still be eligible for family medical leave. As the manager, you should ensure that the employee is considered for any available family medical leave time or an Americans with Disabilities Act accommodation.