1 THE STANDARD LIFE INSURANCE COMPANY OF NEW YORK Long Term Disability Insurance Benefits Guide For The Employees of The State University of New York Answers to your questions about coverage from The Standard Life Insurance Company of New York
2 This booklet is not a contract or policy of insurance. It contains general information and a series of questions and answers intended to explain some of the major features of the coverage provided by the group policy and certificate. The specific terms of your group policy and certificate will govern any claim for benefits you may make. Possession of this booklet does not necessarily mean you are insured. You are insured only if you meet the requirements set out in the Group Long Term Disability Insurance Certificate.
3 Applying for Disability Benefits This booklet gives you the information you ll need when you apply for disability insurance benefits from The Standard Life Insurance Company of New York (The Standard). The Standard has made this process as simple as possible by providing a step-by-step approach for you to follow. If you need help along the way, just call us toll free at , and you ll reach a caring person who is ready to answer your questions. We re here to make sure you receive all the benefits for which you are eligible as soon as possible. Knowing how and when to begin the disability benefits application process always seems to generate a number of questions. Here are often-asked questions and answers about The Standard s group disability coverage to help start the process. What exactly is disability insurance? Disability insurance helps to replace a percentage of earnings, as defined in your group insurance certificate, if a covered employee becomes disabled under the terms, limitations and conditions of the group certificate. The Standard pays a regular monthly benefit during the time a covered employee is disabled and cannot work. How can I tell if my disability is covered under The Standard s group disability plan? Check your certificate of insurance for the definition of disability or disabled to determine how it may apply to your situation and condition. Contact your employer and The Standard for guidance and assistance if you are unsure. When should I apply for benefits? You should apply for benefits as soon as you and your doctor determine that you may be disabled beyond the elimination period ideally within three months of ceasing work. What exactly is the elimination period? You must be disabled for a specific period of time (called the elimination period) before benefits can be paid. This time period varies from policy to policy, but usually is either three or six months. Check your certificate of insurance for your elimination period. Will I receive any income during the elimination period? Ask your employer about your eligibility for salary continuation during periods of absence from work. Some employers may offer short term disability insurance. In addition, some states offer government-sponsored insurance that provides income during this period. How do I apply for The Standard s disability benefits? Obtain a disability benefits application from your employer or call The Standard at Complete all necessary sections and make sure that your doctor submits the Attending Physician s Statement and all medical records related to your disability. Long Term Disability Insurance 1
4 Am I eligible for any other benefits? You may be eligible for Social Security disability benefits. If your disability is jobrelated, you may be eligible for workers compensation. You might also be eligible for state retirement system disability benefits or benefits from other plans. Check with your employer or contact The Standard. How do I apply for Social Security benefits? Contact your local Social Security office. You may also call the Social Security Administration at Can The Standard help if my application for Social Security disability benefits is denied? Yes, help may be available through The Standard. When disability benefits begin, how much income will I receive each month? Your monthly benefit formula is shown in your certificate of insurance. Under most of The Standard s group policies, it is 60 percent of salary, up to a certain specific monthly limit, minus the amount of benefits payable from other sources, such as Social Security (including any benefits paid to your dependents as a result of your disability), workers compensation and perhaps other sources. Does my doctor get involved with the application process? Your doctor plays an important role. We rely on your doctor and all other medical practitioners and institutions involved in your care for complete information on your condition. We need this information to give complete and proper consideration to your claim. It is important for you to let your doctor know about your need for cooperation as soon as possible. Slow responses by doctors in providing necessary medical information are the main reasons for delays in processing claims. Please be sure that medical records are submitted along with the Attending Physician s Statement. What happens if my application for benefits is denied? The Standard has a process for appealing denied claims. Suppose I have been disabled for a while and think I m ready to return to work. What should I do? Talk with your doctor, your employer and The Standard. Even if you aren t able to perform the duties of your former job, your employer may have another, more suitable position available. If you need training for a different job, The Standard may be able to help you. What if I return to work and find I m really not well enough to continue working? If this happens within a year after you return to work with your same employer, under certain circumstances you may qualify to resume receiving disability benefits without satisfying an additional elimination period. Does The Standard provide rehabilitation services? Yes, we do. In some cases, The Standard will provide the services necessary to help you get ready to resume work. 2 The Standard Life Insurance Company of New York
5 Here s an alphabetical list of documents you ll need as you go through the process of applying for and continuing disability benefits: Additional Medical Information, such as physical findings, laboratory and other test reports, examination reports, X-rays, hospital records all to be provided by your doctor Application Attending Physician s Statement form to be completed by your doctor Authorization to Obtain Information form Certificate of Insurance Descriptions of any other group disability benefits available to you Education, Training & Experience form Evidence that you have applied for disability benefits from all sources and the outcomes of those applications Job description from your employer Medical history to be provided by your doctor These are the steps to take in applying for disability benefits: Step 1. Check your Coverage and Certificate of Insurance Check with your employer to make certain you re covered under The Standard s group Long Term Disability insurance policy. Any questions that you or your employer may have about your eligibility and coverage should be directed to The Standard. Read your certificate of insurance. Your employer gave this document to you when you became insured. If you no longer have your certificate, ask your employer for another copy. It contains most of the key provisions of the group policy. Pay particular attention to: Definition of disability Elimination period (the period before benefits begin) Amount of benefits payable Effect of benefits from other sources, such as Social Security, in determining how much you will receive if your benefits are approved Step 2. Review the Definition of Disability In your certificate of insurance, you ll find a section entitled definitions. Look up disability. Since each policy has its own definition, make sure that you review the definition of disability that applies to your certificate. Step 3. Review Disabilities Not Covered Every policy has exclusions for which benefits will not be paid. The exclusions will vary from policy to policy. For example, sometimes we won t cover disability caused by war, self-inflicted injury, participation in a riot or felony or a pre-existing condition. Read the Disabilities Not Covered section of your certificate and see if any apply to you. Long Term Disability Insurance 3
6 Step 4. Estimate the Length of Your Disability How long do you expect to be out of work? If you re able to return to work within the elimination period specified in your certificate, benefits would not be payable. However, if there is any chance that your disability may extend beyond that elimination period, apply as soon as possible after you stop working, so that we have time to reach a decision before benefits are due. Can you continue to perform your current job? Can you perform a different job that uses your skills and education? Can you work at all? These are all questions you should discuss with your employer and your doctor. Step 5. The Disability Benefits Application You, your employer and your doctor must provide satisfactory written proof of your disability. We suggest that you explain to your doctor the importance of complete, prompt responses to our request for information. The sooner we receive the necessary information, the sooner we can make a decision on your claim for benefits. Here s a list of the most likely supporting documents we ll ask you to provide: From You The Employee Statement section of the application booklet, including the addresses of doctors A complete work history The Authorization to Obtain Information form permitting us to obtain additional information, including medical and benefit information from other sources such as Social Security Evidence you have applied for all benefits from other sources with copies of their approval or disapproval of your application A Repayment Understanding Agreement form that confirms you will repay The Standard if an overpayment occurs as a result of other types of income or benefits Information about when you expect to return to work and any related plans you may have From Your Doctor Copies of your doctor s office notes and other medical records, including: Physical findings Laboratory and other test reports Examination reports X-rays Hospital records Consultant reports Your complete medical history 4 The Standard Life Insurance Company of New York
7 An Attending Physician s Statement form gives general information about your disabling condition. Information provided on or with this statement should give a clear picture of your abilities and limitations with an explanation of why the limits apply and information about any plans to return to active work. If there is more than one physician involved in the care of your disabling condition(s), please duplicate the Attending Physician s Statement and request that each physician complete and return the form and their records to The Standard. From Your Employer Salary and attendance records Description of any other group disability benefits available to you, including workers compensation, if applicable Your job description The sooner we receive the completed application booklet, the sooner we can begin evaluating your claim. Step 6. Contact Your Employer Your employer can supply the application booklet you need to apply for benefits. If you need more information about the application, call Step 7. Social Security Application Process If you are disabled, you are probably eligible for Social Security disability benefits. These benefits generally begin after five full months of total disability. Apply for them before or at the same time you apply for your long term disability benefits. Here are four very important reasons why you should apply for Social Security disability benefits. Your Standard Disability Benefit is Affected The Standard coordinates our benefit with your Social Security benefit (including any dependents benefit). Your LTD benefit will be reduced by the income your receive or are eligibe to receive from Social Security. Higher Retirement Benefits If Social Security approves your disability application, your earning status will be based on your salary level in effect just before you became disabled. This means your retirement and other Social Security benefits won t be decreased because your earnings decreased during disability. Medicare You are automatically eligible for Medicare after receiving Social Security disability benefits for 24 months. Long Term Disability Insurance 5
8 Cost-of-Living Increases In our calculations, we use the amount of the Social Security benefit in effect at the time our benefits begin. You keep any cost-of-living increase you receive from Social Security as additional income. Starting the Social Security Process Because Social Security disability benefits begin after five full months of disability, you should apply before or at the same time as you apply for your long term disability benefits. If possible, apply in person at your local Social Security office. Before you go, Social Security prefers that you make an appointment by calling If you are not able to apply in person, call Social Security to make other arrangements. Have the following information available: Birth certificate or other proof of age Social Security numbers your own and your dependents The date your condition began and the date you stopped working The names, phone numbers and addresses of all doctors, hospitals and/or medical facilities treating your condition(s) Claim numbers for any government pensions, workers compensation, state disability or veteran s benefits you are receiving or have applied for Your medications and the dosages Any restrictions the doctor has placed on you A record of your work history and current daily activities As soon as you receive Social Security s decision, send us a copy of the notice. Social Security Assistance Program If Social Security denies your application, The Standard will review your claim to determine if an appeal is appropriate. If so, it will be your responsibility to: Pursue any appeals for Social Security benefits The Standard deems appropriate Send The Standard proof that you have appealed Repay The Standard if an overpayment occurs as a result of a Social Security appeal approval If you ve been approved for The Standard s disability benefits, we can help you to secure the benefits to which you are entitled. 6 The Standard Life Insurance Company of New York
9 Here s what you need to know about our Social Security Assistance program: 1. It s absolutely free of charge. 2. If you need help, call. We offer assistance for the appeals process. 3. If you re approved for Social Security, you may also be eligible for: Higher Social Security retirement and survivor benefits Social Security benefits that may be totally or partially tax-free Medicare coverage (after 24 months of benefits) Reduced health insurance premiums Trial work period If your Social Security application is denied, the first step is to file an appeal within 60 days after you receive the denial notice. In some areas there are three main steps in the application appeal process; in other areas the reconsideration step is skipped and you move directly to the hearing stage. If your request for reconsideration is denied, don t be discouraged. The crucial step in the appeal process is the hearing, which you should request within 60 days after your reconsideration is denied. The hearing is held before an administrative law judge, so it might be a good idea to consult a lawyer who specializes in Social Security applications to represent you. Keep in mind that we are ready to work closely with you, whether or not you hire an attorney. A significant number of denials are reversed at these hearings, and we will do our best to help you turn a no into a yes. Step 8. Your Benefits From Other Sources If disability is caused by an on-the-job accident or illness, you may be eligible for workers compensation. You may also be eligible for sick leave or retirement disability benefits. If you are in doubt about your eligibility, check with your employer. If you are eligible for such benefits, you should notify The Standard immediately. Step 9. Calculate Your Benefits Every disability plan has a formula for determining the amount of monthly income benefits, a maximum monthly income benefit amount and, in some cases, a minimum monthly income benefit amount. The amount of your monthly income benefit from The Standard is reduced by the amounts of certain benefits from other sources, such as Social Security, workers compensation and certain other sources of income. See your certificate for the exact provisions and benefits from other sources that are reductions under your employer s plan. Long Term Disability Insurance 7
10 Here s a typical example of how The Standard s monthly income benefit is calculated: Basic Annual Wage $25,000 Benefit Formula Percentage 60% Maximum Monthly Income Benefit $3,000 Minimum Monthly Income Benefit 10% of the Monthly Income Benefit before offsets or $100.00, whichever is greater Monthly Wage Base $2, ($25,000 divided by 12) Monthly Income Benefit (before offsets) $1,249.99* ($2, x 60%) Minus Benefits From Other Sources Social Security $ Other Benefits 0.00 Monthly Income Benefit $704.99** from The Standard * This amount cannot be greater than $3,000 in this example. ** This amount cannot be less than the minimum that applies in this example. See your certificate of insurance for the provisions under your employer s plan. 8 The Standard Life Insurance Company of New York
11 Use this calculation to determine your benefits: 1. Your Basic Annual Wage Base $ 2. Divide amount from line 1 by 12 $ 3. Multiply amount from line 2 by benefit formula percentage* $ 4. Maximum monthly income benefit payable if less than amount from line 3.* $ 5. Minus Social Security benefit $ 6. Minus benefits from other sources $ 7. Monthly Income Benefit from The Standard $ 8. Minimum Monthly Income Benefit if greater than amount on line 7.* $ * For the actual percentage to use in determining your total monthly income benefit and for the amount of your maximum and minimum monthly income benefit see your certificate of insurance. Step 10. Provide Additional Information It s very important that we have all the medical and vocational facts about you. To obtain additional information, we may require such things as a personal interview, an independent review of your activities, a vocational survey or job analysis or an independent medical examination (at our expense). Periodically, we will ask you to provide updated information. Step 11. The Standard s Decision Notification The Standard will notify you in writing when we have made a decision on your disability application. If your application is declined, you may request a review of the decision. Just write to The Standard within 180 days after you receive written notice of the denial to request review of the decision. Provide us with any additional evidence to support your claim. Your claim will be reviewed by another individual who did not participate in the initial decision. For more information, read the section of your certificate of insurance covering notice of decision on claim and review procedures. Long Term Disability Insurance 9
12 Benefits Begin The Monthly Payment If your application is approved, The Standard will send you a monthly income benefit payment for as long as you remain eligible under the terms, limitations and conditions of the policy. Checking Back with Your Doctor Your physician must confirm your ongoing disability by completing the Attending Physician s Statement and providing documentation to support your limitations and restrictions. We may ask a consulting physician to review your records or call in an independent medical examiner to conduct a medical examination (at our expense). We also may review your benefit status by means of an on-site evaluation. We usually use outside agencies to perform this service. Taxation of Disability Benefits We strongly suggest you contact your accountant or tax advisor for tax advice. Note that your disability benefits including those payable under Social Security may be taxable. How Social Security Benefits Are Taxed By January 31 of each year, you should receive a Form SSA-1000 stating the total Social Security benefits paid to you in the previous year. For some, these benefits will be entirely tax-free. For others, you may find part of your benefits subject to tax. For complete information on current laws and how they affect you, consult your Social Security office, the IRS or a tax advisor. How Your Disability Benefits from The Standard Are Taxed The tax laws are complicated, and you should contact your tax advisor or the Internal Revenue Service to determine how your benefit from The Standard is taxed. Generally, the taxable amount is determined by who paid for the disability insurance premium and whether the premiums were paid on a before-tax or after-tax basis. For any premiums you paid for on an after-tax basis, the equivalent percentage of your benefits will not be taxed. Those premiums you paid for with before-tax dollars under a flexible benefit program will be taxed. Any benefits resulting from premiums paid by your employer on a before-tax basis are subject to taxation. There is a tax credit a specified sum you can deduct from your taxes if you are permanently and totally disabled. For information about the applicable tax credit, read the instructions for your federal tax return or consult the IRS, an accountant or a tax advisor. The IRS prepares Publication #524, Credit for the Elderly or Disabled, which you may find helpful. You can order a copy of this publication by calling Rehabilitation At The Standard, we know that disabled persons often have complex rehabilitation needs, making progress and recovery different for each individual. We can help provide the guidance and expertise you need to facilitate your return to work. 10 The Standard Life Insurance Company of New York
13 Rehabilitation works best when we all work together as a team. We ll combine your abilities and commitment, the efforts of your regular medical provider, and the expertise of our rehabilitation professionals to prepare you to work to the fullest extent of your abilities. The decision to return to work calls for communication among your doctor, your employer, your family, The Standard and you. There are many factors to consider: Your medical condition Your ability to perform the job Your physical limitations The Standard s rehabilitation services can offer assistance and direction. Check your certificate of insurance for special provisions that affect you and call The Standard to see how we can help you return to work. If you do return to work, it is your responsibility to contact The Standard immediately and provide us with the details of your plan. The Standard s Services Our Vocational Case Managers specialize in disability rehabilitation and work closely with outside agencies and institutions throughout the nation. They work with you to formulate a written statement of services designed to assist you in returning to gainful employment. With our assistance and direction, together with your motivation, you may be able to achieve full or partial recovery. You may return to your former job or an equally rewarding job elsewhere. Our services, focused on guiding you to a rewarding level of achievement, may include: Medical case management Vocational assessment Vocational testing Counseling Training Placement assistance Eventually, your doctor, your employer and you may conclude that you cannot resume your former job, but you may be suited for another position. The Standard may help identify job retraining. Perhaps your employer will also take an active role in finding an appropriate new job and in training you for it. Our Vocational Case Managers periodically review the medical information in your file and track your progress. If they think you are a good candidate for rehabilitation services, they will contact you. But you don t have to wait to hear from us. If you think you might be ready to return to work, contact a Vocational Case Manager to answer your questions and concerns. They can be reached at and are able to discuss your situation with you. Long Term Disability Insurance 11
14 Here are some questions you should ask your doctor, your employer, The Standard and yourself: Questions for Your Doctor Am I able to return to work part- or full-time? What limitations do I have? If I need special job modifications, can my doctor contact my employer directly about them? Questions for Your Employer Can I return to my previous job, either part- or full-time? If my former job is not available, is there another job consistent with my education, training and experience? What do I need to do in order to return to work? Questions for The Standard What kind of rehabilitation services does The Standard offer? What happens if I need training for a new job? Do I have to pay for any of The Standard s services? Questions for You What other employers in my area offer job opportunities? What training might I need to return to work? Should I contact any voluntary or professional organizations that might help me to resume work, such as a labor union, a state employment service or vocational rehabilitation service? Have I contacted a Vocational Case Manager at The Standard? If your answer to the last question is no, call us toll-free A Vocational Case Manager will be able to discuss your situation with you. If Return to Work Proves Unsuccessful We believe that it is in the best interest of a disabled person to return to work as soon as possible. But what if you try and fail? If you were receiving disability benefits, return to work on a full-time basis with your same employer and cease working due to the same or related cause within the timeframe noted in your certificate, we may resume paying disability benefits without your having to satisfy a new elimination period. Additional Rehabilitation Help Sources There are millions of disabled people throughout the United States. A number of organizations provide information and support: Federal Programs Office of Disability Employment Policy, Washington, D.C. Telephone: The Standard Life Insurance Company of New York
15 Veterans Affairs/Rehabilitation, Washington, D.C. Telephone: For an up-to-date listing of all federal programs for the disabled, contact: Able Data (Assistive Technology & Rehab Product Database) 8455 Colesville Road, Suite 935 Silver Springs, MD Telephone: National Rehabilitation Information Center Telephone: Voluntary Programs American Hospital Association, Chicago, IL Telephone: National Rehabilitation Association, Alexandria, VA Telephone: Mental Health Law Project, Washington, D.C. Telephone: ADA Information Telephone: To find out about similar organizations in your area, check your phonebook under State Office or ask for local branches of the organizations listed above. When Benefits End There are various reasons why your benefits will no longer be paid. These include, but are not limited to: when you are no longer disabled as defined in the policy, when you reach the age or other duration limits specified in the policy, if you do not provide written satisfactory proof of continued disability or if you refuse to keep an independent medical examination appointment. We suggest you review your certificate of insurance for the specific provisions that apply to you. In all cases when benefits are terminating, The Standard will notify you in writing. Transition to Retirement Benefits If you are still disabled as you approach retirement age, contact your employer to find out about retirement benefits that may be available to you. If you re covered under your employer s pension plan, it s a good idea to contact them several months in advance to plan the transition from disability to retirement benefits. Long Term Disability Insurance 13
16 Call on The Standard We re Here to Help We ll provide assistance at every step along the way. If you have any questions just call our toll-free number: You can also contact us by mail: The Standard Life Insurance Company of New York P.O. Box 5031 White Plains NY The Standard Life Insurance Company of New York
17 The Standard Life Insurance Company of New York P.O. Box 5031 White Plains NY SNY (4/10)EE GPNY0500-LTD
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