Understanding Short-Term Disability Benefits Eligibility
If you suffer a disabling injury or illness that requires treatment and appropriate medical care for a short period of time (typically 12 months or less), short-term disability (STD) insurance benefits can provide you with income replacement. Your short-term disability income replacement benefits are based on your monthly income, along with a predetermined percentage of this income that your plan or individual policy will pay out each month in the event of a covered, short-term disability after a waiting period.
As with long-term disability (LTD) insurance, not every STD policy covers every injury or illness—however disabling it is. Examples of commonly excluded short-term disabling conditions are, mental illness and usually workers’ compensation related claims.
Your STD disability insurance policy should detail which conditions are included and categorically excluded. Most STD plans cover:
- Neck, back, knee, and hand issues
- Heart attack
- Gastrointestinal problems
- Lyme Disease
- Injuries sustained outside of work
Your policy will inform you about specific short-term disability benefit start and end dates, the percentage of your monthly income, and the requirements for benefits.
To receive short-term disability benefits through any insurance company, the policyholder must first file a timely claim and meet all ”proof of loss” requirements.
Significant Terms to Remember
Despite variations in language between insurance company policies, major insurance companies tend to use similar concepts, terms and definitions relevant to individual STD or group STD benefits, including:
- Initial enrollment period: A new employee is often eligible to sign up for group employer-provided disability insurance coverage during an open enrollment period. You will receive this information upon hire. If you have questions, contact your human resources department for more information. This period is often a defined window from the start of your employment until a certain date past which your eligibility for enrollment ceases, absent certain life changes. Thirty-to-sixty day enrollment periods are common. Remember, initial or open enrollment is optional in many cases, the failure to enroll will mean that this optional plan will not cover you in the event of a short-term disability.
- Minimum service period: For STD disability insurance that an employer provides, the employer may require that employees are employed for a specified amount of time before they receive coverage.
- Elimination period: This term refers to the amount of time between the onset of a claimant’s disability and the point at which the claimant becomes eligible to receive monthly disability benefits. Often, eligibility is not at the same point as the disability’s onset. Instead, the claimant must wait a specific amount of time before eligibility and payments kick in. For this reason, the elimination period is also known as the “waiting period.” Individual and group insurers normally communicate this, and more, in the policy booklets or certificate you receive.
- Pay cap: This term refers to the total amount of monthly disability benefits to which a particular insurance policy entitles a claimant to receive. In the event a claimant has purchased multiple insurance policies, insurers often offset the amount of money they pay out each month by the amount that the claimant receives from other sources to ensure that an over-insurance situation doesn’t occur.
More About Short-Term Disability
Insurance companies limit who has access to disability benefits through exclusions or pre-existing conditions. An individual can’t receive a diagnosis, schedule a medical procedure, and then purchase short-term disability insurance expecting to be covered.
Can I Get Temporary Disability After Surgery?
Sometimes, you might have to miss work because you need surgery, whether it is sudden or scheduled. If the illness or injury that prompted the surgery does not prevent you from doing your occupation, you want to be sure you can survive recovering without benefits. If you know about your surgery ahead of time, discuss your options with a disability attorney.
Some states require the availability of short-term disability benefits, which might come from a state fund consisting of employer and/or employee contributions. State law might also require employers to provide this coverage, such states like New York, New Jersey, California, Hawaii, and Rhode Island. If your state requires short-term disability insurance programs, speak with your disability lawyer, the state labor department, or your employer’s human resources department about how to set up benefits before your elective surgery.
Even if the law does not require it, your employer might voluntarily provide short-term disability insurance to employees, to which employees might need to contribute in the form of paycheck deductions. If you have this coverage, you can obtain information about the coverage, benefits, claim process and criteria from your employer or H.R.
Some people have short-term disability coverage they purchased on their own. If you are in this situation, never hesitate to contact the insurance company to discuss coverage and how you can set up benefits for after your surgery.
If you encounter any problems getting the coverage you deserve, call a disability lawyer for help.
Common Procedures that Lead to Short-Term Disability
Many disability insurance policies exclude pre-existing conditions from short-term disability coverage. Rules may govern surgery for pre-existing conditions you had when you obtained the policy. In this situation, some insurance companies might require you to carry insurance coverage for a certain amount of time before you qualify for the surgery benefits, so you want to review your policy with a disability attorney.
If you have coverage, you should qualify for short-term disability benefits following most medically necessary procedures.
Some examples of surgeries that lead to short-term disability awards include:
- Gallbladder removal or removal of other organs
- Hip or knee replacement
- Surgery to repair fractures or soft tissue tears
- Birth by Cesarean section
- Open heart surgery
While you cannot work following many of these procedures, short-term disability can replace some of your income, relieving financial stress from you and your household. Typical benefits might last for three to six months, depending on your recovery time. Keep in mind that you might have a waiting period before benefits begin, so you may see a gap between the surgery and the start of weekly or monthly disability payments.
If you know about the procedure ahead of time, take the opportunity to learn about your short-term disability options and how you need to go about obtaining your benefits. This way, if your insurer denies your claim, you have time to appeal with the right legal assistance. If you have emergency surgery, seek help from a disability attorney right away. He or she can handle your claim while you are in the initial recovery stage.
You May Have More Options After Wrongful Disability Denials
- A false assertion that your disabling condition was pre-existing and does not qualify for benefits under your policy
- An insurer-hired doctor without the proper training or specialization reviews your file and determines that you are not disabled, or talks to your treating doctor and determines that you are ready to return to work before that is actually possible
- You were surveilled by a private investigator who collected “evidence” video and photographic that your insurer alleges is inconsistent with your reported restrictions and limitations.
Keep All Papers and Documents Related to Your Disability Claim
If your disability claim is wrongfully delayed or denied, you may only get a different outcome by fighting back.
Keeping or retrieving copies of all correspondence between you and your insurer helps you to do that, and it helps us help you. Such documents can include, but are not limited to:
- Any correspondence to and from you and your insurer.
- Denial or delay letters.
- Notes and dates from as many phone and email conversations you had with your insurer—or any other relevant professional—relating to the unreasonable delay, wrongful denial, or your administrative appeal. Always try to include information like the day, time, name, and title of the person you talked to, as well as any important information shared or discussed in the conversation.
Find what you can, make note of the documents you remember submitting but can’t locate, and save everything moving forward.
If Your Disability Claim Was Wrongfully Delayed or Denied, Please Contact Us Today!
The top-rated, seasoned attorneys at the nationwide disability insurance law firm DarrasLaw have recovered millions on behalf of disabled individuals who were wrongfully denied the benefits to which they were entitled.
Common red flags we have seen that indicate bad-faith delays or wrongful denials of disability coverage include:
- Requests for independent medical examinations with doctors in the wrong specialty or with inadequate training
- Massive requests for the duplicative documentation
- Denials that are unaccompanied by any real explanation or logical proof
- Failing to make a claim decision within a reasonable amount of time
- Failing to relate relevant information to the claimant
DarrasLaw can help you can fight back! We’ve taken on every major disability insurance company and won. Reach out to the top-rated disability insurance lawyers and ERISA attorneys at DarrasLaw at (866) 276-3054 or contact us online for a free policy analysis or claim consultation.