PROCEDURES FOR DETERMINING APPLICATIONS FOR DISABILITY BENEFITS

Transcription

1 PROCEDURES FOR DETERMINING APPLICATIONS FOR DISABILITY BENEFITS The Board of Trustees ("Board") of Lubbock Fire Pension Fund ("Fund") hereby adopts the following Procedures to determine all applications and claims for disability benefits including but not limited to the determination of initial eligibility for disability benefits, and the termination, reduction or reinstatement of disability benefits pursuant to Section 4 of the Fund and Section 14 of Vernon's Annotated Civil Statutes, Art. 6243e. A. APPUCATION FOR DISABIUTY BENEFITS Step 1: Initial Application. The member seeking to qualify for a disability benefit (hereinafter "Member") shall request an application from the Board. At the time of such request, the Board shall supply to the Member the following: a. A statement providing the Board has adopted Procedures for determining all applications and claims for disability benefits including the determination of initial eligibility of a Member for disability benefits. b. A statement providing if after such completed application is received by the Board, and the Board anticipates needing additional information or items in order to determine the application for disability benefits, a request that the same be provided to the Board will be made within 20 days after the completed application is received. c. A statement providing the Member may within 20 days after the date the completed application is delivered to the Board, furnish to the Board additional comments regarding the application and provide additional information to the Board. d. A statement providing if all information necessary for the Board to determine the eligibility of the Member for disability benefits is not furnished to the Board within twenty (20) days after the date requested by the Board, the Board may for lack of sufficient information reach a determination the Member is not eligible for disability benefits. e. A statement providing the Board will review the application for disability benefits at the next regularly scheduled meeting of the Board following the the later of the date of the initial receipt of the Member's application by the Board, or the expiration of twenty (20) days after a request for additional information is made by the Board; based on the information then available to the Board. f. A statement providing the Member may designate by giving written notice to the Board, a representative for receipt of copies and notices which are sent by the Board to the Member with respect to the application; and g. An application for disability benefits. Step 2: A completed application for disability benefits must be returned to the Board. The application must also contain the following: a. A sworn and subscribed statement of the Member's medical condition, signed, by a physician attending the Member;

2 b. A sworn and subscribed statement of the circumstances under which the disability arose, signed by the Member or another person who has reason to know the circumstances; c. Other pertinent information to enable the Board to determine whether the Member is eligible for disability retirement including, but not limited to, laboratory results, x-rays, or any other relevant documentation, medical or otherwise. d. Any other documentation which the Member wishes the Board to consider. Step 3: Determination of Initial Eligibility for Disability Benefits. a. The Board will review the Member's application for disability benefits at the next regularly scheduled meeting of the Board following the later of: the date of the initial receipt of the Member's application; or the expiration of twenty (20) days after a request for additional information is made by the Board. The Member or the Member's designated representative may attend the Board meeting. b. At the Board meeting, the Board will review the application for disability benefits submitted by the Member. The Board may at that time: (iii) vote to approve the Member's application for disability benefits; vote to deny the Member's application for disability benefits; vote to appoint a physician or rehabilitation expert to examine the Member's medical history, along with the application submitted, and a required job description. c. If the Board appoints a physician or rehabilitation expert, the Board shall forward a copy of the disability application along with all medical records to the appointed physician or rehabilitation expert. The Member shall be notified of the appointment of the physician or rehabilitation expert. d. If the Board appoints a physician or rehabilitation expert, at the next regularly scheduled meeting of the Board following the receipt of physician or rehabilitation expert's statement, the Board shall: vote to approve the Member's application for disability benefits; or vote to deny the application or disability benefits. e. If the Board determines it does not have sufficient information to determine whether or not the individual is entitled to disability benefits, the Board may determine for lack of sufficient information that the Member is not eligible. The Board shall enter a statement detailing the determination in the Member's file, and the Board will so notify the Member. 2

3 f. If the Board determines, for one or more specific reasons, the Member is not eligible, the Board shall enter a statement detailing the specific reason or reasons the Board has determined the Member is not eligible in the Member's file and the Board will so notify the Member. g. If the Board determines the Member is eligible for benefits, the Board will notify the Member that the Board has determined the Member is eligible for disability benefits. Such notice shall include the following additional statements: (iii) A statement providing the Board's determination of the disability benefit is subject to termination, reduction, or reinstatement pursuant to Section 4.05 of the Fund. A statement providing a Member receiving disability benefits must provide, when requested by the Board, a completed Continuing Disability Benefit Application. A statement providing the Member shall provide all necessary information to the Board to enable the Board to process the application for disability benefits. B. APPLICATION FOR CONTINUING DISABILITY BENEFITS Step 1: Application for Continuing Disability Benefits. The Board may request the Member receiving disability benefits complete an application for continuing disability benefits to be provided by the Board and submit the same to the Board within sixty (60) days of the Board's request. At the time of such request, the Board shall supply to the Member the following: a. a statement providing the Board has adopted Procedures for determining applications and claims for disability benefits. b. a statement providing if after such completed application is received by the Board, the Board anticipates needing additional information or items to consider the application for continuing disability benefits, a request that the same be provided to the Board will be made within twenty (20) days after the completed application for continuing disability benefits is received. c. A statement providing the Member may within twenty (20) days after the date the completed application for continuing disability benefits is delivered to the Board, furnish to the Board additional comments regarding the application and provide additional information to the Board. d. A statement providing if all information necessary for the Board to determine the eligibility of the Member for continuing disability benefits is not furnished to the Board within sixty (60) days after the date requested by the Board, the Board will for lack of sufficient information reach a determination the Member is not eligible for continuing disability benefits; e. A statement providing the Board will review the continuing application for disability benefits at the next regularly scheduled meeting of the Board following the later of the date of the receipt of the Member's application 3

4 for continuing disability benefits, or the expiration of twenty (20) days after a request for additional information is made by the Board; f. A statement providing the Member may designate by giving written notice to the Board, a representative for receipt of copies and notices which are sent by the Board to the Member with respect to the continuing application; and g. An application for continuing disability benefits. Step 2: A completed application for continuing disability benefits must be filed with the Board within sixty days of the original date of the Board's request for the continuing disability benefit application. The application for continuing disability benefits must also contain the following: a. A member's statement concerning the current physical or mental status for continuing the disability benefits. b. A statement from the member's attending physician regarding the current physical and/or mental status concerning continuing the disability benefit. c. The initial application for continuing disability benefits must include a sworn and subscribed statement of the member's current financial income supported by copies of the Forms 1040 Federal Income Tax Return, with copies of all W-2 forms filed by the member for the previous two years. All subsequent applications for continuing disability benefits must include a sworn and subscribed statement of the member's current financial income supported by a copy of the member's most recently filed Form 1040 Federal Income Tax Return, with copies of all W-2 forms. Step 3: Determination of Continuing Eligibility for Disability Benefits. a. The Board will review the Member's application for disability benefits at the next regularly scheduled meeting of the Board following the later of the date of the Board's receipt of the Member's completed application for continuing disability benefits; or the expiration of twenty (20) days after a request for additional information is made by the Board. The Member or the Member's designated representative may attend the Board meeting. b. At the Board meeting, the Board will review the application submitted by the Member. The Board may: (iii) (iv) vote to continue the benefit; vote to reduce the benefit; vote to terminate further benefits; vote to appoint a physician or rehabilitation expert to examine the Member and review the Member's medical history and the Member's application; 4

5 (v) vote to continue to pay the disability benefit but reserve the right to ask for more information or statements from the Member to effect a final vote. c. If the appointment of a physician or rehabilitation expert is approved by the Board, the Board will schedule an appointment and forward a copy of the application for continuing disability benefits and all medical records and/or job requirements to the appointed physician or rehabilitation expert. The Member shall be notified of the appointment of the physician or rehabilitation expert. d. At the next regularly scheduled Board meeting following the receipt of the physician or rehabilitation expert's findings, the Board shall: (iii) (iv) vote to continue the benefit; vote to reduce the benefit; vote to terminate further benefits; or vote to continue to pay the continuing disability benefit but reserve the right to ask for more information or statements from the Member to effect a final vote. e. If the Board determines it does not have sufficient information to determine whether or not the individual is entitled to disability benefits, the Board may determine for lack of sufficient information the Member is not eligible for continuing disability benefit. The Board shall enter a statement detailing the determination in the Member's file, and the Board will so notify the Member. f. If the Board determines, for one or more specific reasons, the Member is not eligible for continuing disability benefits, the Board shall enter a statement detailing the specific reason or reasons the Board has determined the Member is not eligible for continuing disability benefits in the Member's files, and the Board will so notify the Member. g. If the Board determines the Member is eligible for continuing disability benefits, the Board will notify the Member that the Board has determined the Member will continue to be eligible for disability benefits. C. MISCELLANEOUS 1. Giving Notice. Any notice to be given by the Board to the Member hereunder shall be mailed to the last known mailing address of the Member as shown in the records of the Board, unless the Member has specifically stated in a notice actually received by the Board that another address is to be used. Any notice given by the Board shall be deemed given when deposited in the United States mail, postage prepaid, properly addressed, whether or not actually received by the Member. Any notice given to the Board shall be deemed given only when the notice is actually received by the Board. 2. Amendment. The Board may at any time, and from time to time, amend these procedures. 5

6 "]V'- Adopted this 21 day of ThJ...Y, 20 15":./Trustee c4~~ Trustee Trustee F:\CLlENTSILubbock Firemen\DisabilitylProcedures for Detenlllnmg Applications.doc> 6

7 Texas Local Fire Fighter's Retirement Act Application for Disability Benefits Lubbock Fire Pension Fund lubbodcare Disability Benefit Applicant Information: I Address Name City State Zipt I f ; ;:::===============~ Social Security Numberl Ph~~:N~~~~ ~ ~ ~ Applicant's Service Information: Dept Entry Datel Service End Date Amount of Servicef-----y-ea-rs-m-o-n-th-s-d-a-ys------l Rank at Service End f------l=::...:..:.==-=c:= l Monthly Salary at Service End ~=====================:=; The Effective date of the Fund Pension Plan that you are retiring under Nature of Injury and how it was incurred: Classify Disability: Medical Information: DOn-Duty Disability happened while performing responsibilities as a fire fighter DOff-Duty Disability engaged in activities WITHOUT compensation or profit unrelated to fire fighter responsibilities DOff-Duty Disability engaged in activities WITH compensation or profit unrelated to fire fighter responsibilities Examining Doctor: Complete, Sign, and Return to' The swom statement supporting the disability signed by the physician and the Authorization for Releases of Medicallnformalion must be attached to this application to be processed Benefit Disability Benefit Pension Fund lubbock Fire Pension Fund Mailing Address #15 Briercroft Office Park City Sl3te Zip Lubbock. TX Fax I (806) Phone~---~{~806~}~7~62~-~15~9~ ; Applicant's Signature Date The Sl3te of Texas County of Lubbock SWORN AND SUBSCRIBED BEFORE ME this day of 20_. Nol3ry Public, State of Texas My Commission Expires:

8 Texas Local Fire Fighter's Retirement Act Certification and Approval of Disability Benefits Lubbock Fire Pension Fund The following is being certified by the local board: Disability Applicanfs Namel Applicant's Social Security Number:=====================~ Applicant's Service Information: Dept Entry Datel Service End Date Amount of Service~======================~ Rank~ServiceEndr ~ Monthly Salary at Service End L ---' The Effective date of the Fund Pension Plan that you are retiring under Benefit Amount This application must have a calculation sheet for the disablility benefit monthly anuity awarded. A worksheet should clearly identify the elements of the benefit as defined in the Plan and show the calculation of the benefit based on the description in the Plan. Disability Benefit Monthly Amountl-I --i Benefit Start Date '-. Disposition This benefit was reviewed at a local board meeting on \..1 --' o Benefit was APPROVED o Benefit was DENIED (Attach statement with explanation for denial) o MORE INFORMATION REQUIRED: OIRECTNE An ACHED Roger Lindsey, Chairman Date KeVin Ivy, Vice Chairman Date Linda Cuellar, Secretary Date Lubbock Fire Pension Fund #15 Briercroft Office Park Lubbock, TX 79412

9 AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION FUND: LUBBOCK FIRE PENSION FUND MEMBER: ADDRESS: SOCIAL SECURIlY NUMBER: PHYSICIAN: AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION: Member hereby authorizes Physician to furnish to the Fund the results of any physical examination of the Member by the Physician, including, but not limited to, all medical history, medical information, opinions, diagnosis, prognosis, and any and all other information in any way relating to Member's physical condition and medical history. Member hereby authorizes the Fund to request and receive from any and all other physicians, hospitals, other health care providers, insurance companies, governmental entities, and any other persons or entities any and all information about Member's physical condition, medical history and medical treatment, and Member hereby authorizes all such other persons and entities to furnish to the Fund any and all such information now or hereafter requested by the Fund. ACKNOWLEDGMENT BY MEMBER: Member also understands and acknowledges that Member's furnishing to the Fund incorrect, incomplete, and/or misleading medical information will be grounds for subsequently denying Member's benefits under the Fund. BINDING EFFECT: This document is binding on Member, his heirs and personal representatives, and shall inure to the benefit of Fund, Physician, and the City of Lubbock. This document is irrevocable. Date: THE STATE OF TEXAS COUNTY OF Signature of Member BEFORE ME, the undersigned authority, on this day personally appeared, known to me to be the person whose name is subscribed to the foregoing instrument, and acknowledged to me that _he executed the same for the purposes and consideration therein expressed. GIVEN UNDER MY HAND AND SEAL OF OFFICE, this day of 20. Notary Public, State of Texas My Commission Expires: F:\CLlENTS\Lubbock Firemen\Disability\Medical Release-doc

10 SWORN STATEMENT OF PHYSICIAN REGARDING MEMBER'S DISABILITY APPLICATION FUND: LUBBOCK FIRE PENSION FUND MEMBER: ADDRESS: SOCIAL SECURITY NUMBER: PHYSICIAN: STATEMENT OF PHYSICIAN: (If more space is needed, attach additional pages as necessary to this statement) Date: THE STATE OF TEXAS Signature of Physician Printed Name: COUNTY OF SWORN TO AND SUBSCRIBED BEFORE ME this day of,20 Notary Public, State of Texas My Commission Expires: