How To Understand The Short Term Disability Plan

Transcription

1 Chicago Public Schools Short Term Disability Plan Plan Effective Date: January 1, 2012 CPS Short-term Disability Plan rev Page 1

2 TABLE OF CONTENTS PAGE Introduction...3 General Definitions...4 Eligibility and Termination Provisions...6 Claim Reporting....7 Claims and Payment...8 Short Term Disability Coverage Exclusions...12 Appeals Procedure...13 Rights of Restitution and Reimbursement and Subrogation 15 CPS Short-term Disability Plan rev Page 2

3 INTRODUCTION This is the plan document for the Chicago Public Schools Short Term Disability Plan (sometimes referred to as the Plan or the STD Plan ). This document is intended to set forth certain general provisions governing the short term disability plan voluntarily maintained by Board of Education of the City of Chicago (the Board ) for employees of the Chicago Public Schools and for employees of the Board. The Plan's specifications and provisions, including types of benefits, eligibility requirements, and exclusions and limitations on coverage, special procedures and other relevant provisions may be described in the Employee Benefits Handbook, benefit booklets and/or schedules, in plan summaries, collective bargaining agreements or other documents approved by the Board or its delegate. The Plan includes both this document and those other relevant documents, read together. The Plan pays a Daily Benefit intended to replace income lost during periods of disability which have resulted from a non-occupational injury, sickness, or pregnancy. The Date Benefits Start, the Daily Benefit, and the Maximum Benefit Period are explained in this Plan. The terms "you" and "your" are used to refer to the covered employee. This document contains the specific eligibility, benefit and limitation provisions with regard to the Plan. The Plan shall be construed according to the laws in the state of Illinois, and administered in all respects to effectuate this intention, as determined by the Board. Eligible employee are automatically covered on their Coverage Date. No employee contributions are required; no enrollment forms need be submitted. CPS Short-term Disability Plan rev Page 3

4 GENERAL DEFINITIONS These terms have the meanings shown here when italicized. The pronouns "we," "us,""our," you," and "your" are not italicized. 1. Active work means working full time for the CPS or the Board at your assigned location. 2. Board means the Board of Education of the City of Chicago. The Board is the governing body of the Chicago Public Schools. 3. Covered person means an individual who is or who has, upon her or his Coverage Date, become covered by this Plan, and whose coverage has not terminated 4. CPS means the Chicago Public Schools. CPS is governed by the Board. 5. Physician means a fully licensed Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), Doctor of Chiropractor (D.C.), Doctor of Podiatry Medicine (D.P.M.), or a Clinical Psychologist (PHD), other than you, acting within the scope of his or her license to practice medicine and/or perform surgery. 6. Daily Rate of Pay means an amount established by the Board for each employee. 7. Eligible class means a class of persons eligible for coverage under this Plan. This class is based upon employment or membership in a group. 8. Injury means accidental bodily injury. 9. No fault motor vehicle coverage means a motor vehicle plan that pays disability or medical benefits without considering who was at fault in any accident that occurs. 10. Noncontributory means no employee contributions are required. 11. Plan means this Plan Document that describes the benefits for which you may be Eligible 12. Plan Year means each year this plan is in effect. The first plan year will commence on January 1, 2013 and end on a rolling 12 month period. Subsequent Plan Years will commence on the effective date of the approved claim and end on a rolling 12 month period. 13. We, us, and our means the Board and/or Chicago Public Schools. 14. You and your mean an employee who has met all the eligibility requirements for coverage under this Plan. CPS Short-term Disability Plan rev Page 4

5 15. Ten Sick Day Exhaustion Rule means the rule, more fully described under BENEFIT COMPUTATION, the rule requiring exhaustion prior to the beginning of your Period of Disability of a minimum ten sick days from your current year allotment. 16. Disable and disability mean that a non-occupational injury, sickness, or pregnancy prevents you from performing the essential duties of your regular position with CPS or the duties of any suitable alternative position with CPS. Furthermore, you must be under the regular care and attendance of a physician. In addition, time off work for maternity will be treated as a disability under rules established by the Board even though the employee might actually be able to perform his or her duties. Standard approval periods for maternity leave are as follows: six (6) weeks for a vaginal delivery, and eight (8) weeks for a cesearean section delivery. 17. Period of disability means the time that begins on the following day you have satisfied the Ten Sick Day Exhaustion Rule and ends on the day before you return to active work. 18. Maximum Benefit Period is a period of no more than 90 days. It begins on the first day of your Period of Disability and ends on the earlier of 90 days or the end of your Period of Disability. 19. Date of Disability means the date that STD benefits are payable following the exhaustion of the Ten Sick Day Exhaustion Rule. CPS Short-term Disability Plan rev Page 5

6 ELIGIBILITY AND TERMINATION PROVISIONS Eligibility and Effective Date Who is Eligible for Coverage All employees of the Board or of CPS, who are members of an eligible class. Eligible Class is defined as: a) Collectively Bargained Employees; or b) Non Union Employees (Employees who are not members of a bargaining unit); AND both classes who meet all the following criteria: 1) Who are benefits eligible employee under Board rules or policies; and 2) Who are actively employed in their position with CPS Effective Date of Coverage Employees eligible on the Effective Date of the Plan shall be covered on that date. For newly eligible employees, coverage begins on the first calendar day of the month following a 60 day waiting period beginning on the date of hire. Employees who are rehired within 12 months from the date of the employment termination with CPS will be eligible for coverage as of the date of rehire as long as they worked 60 days in their prior employment with CPS. Termination of Coverage An employee s coverage ends when the individual is no longer a member of an eligible class, when the Plan ends, or when the employee retires, terminates employment or dies, whichever is the first to occur. CPS Short-term Disability Plan rev Page 6

7 Claim Reporting When and How to File a Claim If you meet the eligibility requirements and you have a medical condition that renders you unable to work, you must initiate your claim within 10 calendar days from your date of disability by contacting the Claim Administrator at In addition to filing a claim with Sedgwick, an employee must complete the Family and Medical Leave (FMLA) Application for Employee s Own Serious Health Condition. Untimely Reporting of a Claim If you do not report your claim within 10 calendar days from your date of disability, your disability will be considered from the date it was reported and the time period prior to the reported date will be denied. CPS Short-term Disability Plan rev Page 7

8 Claim and Payments Ten Sick Day Exhaustion Rule For any Period of Disability, the Ten Sick Day Exhaustion Rule requires, prior to the beginning of your Period of Disability that you use ten sick days Additional rules also apply: For new hires, the 10 sick day exhaustion rule will be applied based on prorated months of service. The Ten Sick Day Exhaustion Rule is a 12 month rolling look back for each period of disability. A day may not be used to satisfy the rule if the employee receives any amount of compensation for that day from the Board under Workers Compensation, or any settlement agreement. Amount of the Benefit you Receive The base pay used to calculate your short term disability benefit is: Hourly base pay x Scheduled hours = Weekly base pay If you have a change in your base pay while on disability, your base pay used to calculate your Short-term disability benefit will be adjusted based on the new salary rate. Benefits are Taxable Short term disability benefits you receive from the Plan are taxable income. Federal and applicable state and local taxes are withheld from benefit payments. Computation of Benefit Amount: The Weekly Benefit for each covered person is a percentage of that individual s weekly base pay. The daily benefit for partial weeks will be based on 1/5th of the weekly benefit amount. The hourly rate of pay shall be determined by the Board. The percentage shall be: Calendar Days 1 30: 100%. During the period beginning on the date of disability, and continuing up to and including the 30 th day, the percentage shall be one hundred percent of the Daily Rate of Pay. CPS Short-term Disability Plan rev Page 8

9 Calendar Days 31 60: 80%. During the period beginning on the 31 st calendar day from the date of disability, and continuing up to and including the 60th day, the percentage shall be eighty percent of the Daily Rate of Pay. Calendar Days 61 90: 60%. During the period beginning on the 61 st calendar day from the date of disability, and continuing up to and including the 90th day, the percentage shall be sixty percent of the Daily Rate of Pay. Supplemental Income with usage of Sick Days An employee may supplement the STD payment in days to reach 100% income during such period(s) by usage of sick days from their sick day bank(s). Employee must complete the authorization form and elect the specific banks for deductions. Please note, usage of sick days is not an automatic process. Failure to complete the authorization form within the time period will result in no sick day usage during the eligible period(s), and no retroactive sick day usage will be applied to past claim period(s). Payment of Daily Benefit Daily Benefits shall be paid for each regular work day for which the employee would have been scheduled had the employee not been disabled, but only for days during the Period of disability but not in excess of the Maximum Benefit Period. Examples of days not paid by STD include; Holidays, Snow days, and Intercessions. Due to the duration of summer intercession, claims will be closed as of the last scheduled work date had the employee not been disabled. If the employee remains disabled beginning with the first scheduled work date following the end of the summer intercession, the employee will be responsible for contacting the plan administrator to submit a new claim. Reduction of Benefit Payments Benefits paid under the Plan are reduced by the total amount of certain other income for which you may be eligible during any period of disability. These sources of other income are any: Any settlement, judgment, or other recovery from any person or entity, including your own automobile or liability carrier which provides benefits that are intended to replace any portion of your pay Any amount of STD benefits paid for days determined later that benefits were not due. In the case that there are future benefits, overpayments will be deducted from benefits due. CPS Short-term Disability Plan rev Page 9

10 When are Claim benefits payable? We will pay benefits biweekly, for the prior period for which we are liable, after we receive the required proof. If any amount is unpaid when disability ends, we will pay it when we receive the required proof. To Whom are Claim benefits payable? We will pay all benefits to you, if you are legally competent. If you are legally incompetent, we will pay benefits to the guardian of your estate. If any amount remains unpaid when you die, we will pay your estate. When Payments Begin And How Long They Continue Short-term disability benefit payments begin on the first day after you have exhausted ten sick days from your current fiscal year s allotment. You must be under the care of a physician who verifies, to the satisfaction of the Claims Administrator, that because of your disability you are unable to perform the essential duties of your employment with CPS Once you begin receiving short term disability benefits, your benefits continue until the earliest of the following events occurs: You no longer have a covered disability under the Plan. Either you are able to resume the essential duties of your regular position or a position at CPS that accommodates your medical restrictions; The first day for which you are unable to provide satisfactory medical evidence of a covered disability; You do not follow the treatment plan ordered by your physician; You fail to cooperate with a scheduled independent medical examination (IME) or functional capacity evaluation (FCE); You begin work similar to your work with CPS for wage or profit with another employer or through self-employment; You have received benefits for a 90 day period; You are incarcerated; Your employment ends for any reason, including retirement; You die; or The Plan terminates. CPS Short-term Disability Plan rev Page 10

11 Duration of Short-term Disability and Successive Periods of Disability Short-term disability allows you to continue to receive a full or partial salary for up to 90 days in a rolling 12-month period. A rolling 12-month period is measured backward from the date you used any Short-term disability. For example, if a requested Short-term disability was to begin on July 1, the 12 months preceding that date would be reviewed to determine whether any Short-term disability time had already been used. If so, that time would be deducted from the remaining amount of Short-term disability time available. Documentation of Disability You will be required to provide certain information to Claim Administrator in order to have your request reviewed 1. A signed medical information authorization form 2. Medical documentation of objective findings to support your medical condition from your health care provider Objective findings of a disability are necessary to substantiate the period of time your physician indicates you are unable to work because of your disability. Objective findings are those your physician observes through objective means, not your description of the symptoms. Objective findings include: Physical examination findings (functional impairments/capacity); Diagnostic test results/imaging studies; Diagnoses; X-ray results; Observation of anatomical, physiological or psychological abnormalities; and Medications and/or treatment plan. Physical Examination Claim Administrator may also require you to undergo an independent medical examination and/or a functional capacity test. If you do not cooperate with this request (for example, you fail to keep a scheduled appointment), your benefits may be terminated. If the Claim Administrator requests that you undergo an independent medical examination (IME) and/or a functional capacity evaluation (FCE), the charge for such examination will be at CPS expense. Rehabilitation Services At our discretion, we may ask you to participate in rehabilitation services. CPS Short-term Disability Plan rev Page 11

12 Short-Term Disability Coverage Exclusions We will not pay benefits for any part of a period of disability: 1. Resulting from a work-related injury for which you are receiving workers compensation benefits; or 2. Resulting from participation (or as a consequence of having participated in) the commission of a felony; or 3. Resulting from any act of war declared or undeclared, service in the armed forces of any country, performing police duties as a member of any military organization; or 4. Resulting from a cosmetic procedure. However, disability benefits will be paid for reconstructive surgery following a mastectomy; for surgery the Medical Plan determines to be medically necessary; and for complications that prevent your return to work within the normal recovery period for a cosmetic surgery procedure. CPS Short-term Disability Plan rev Page 12

13 Appealing a Denied Claim In the event a claim for Short-term disability is denied, Claim Administrator will send a letter with the following information: The specific reason(s) for the denial, Specific reference to all pertinent provisions upon which the denial is based; and Appropriate information as to the steps to be taken if you wish to submit an appeal for review of the claim denial. Claim Appeal Procedure Level 1 To appeal a denied claim Short-term disability, you must request the appeal in writing, no more than 30 days from the date of the denial. Requests for review of a denied claim should be sent to Claim Administrator at P.O. Box 14446, Lexington, KY , or fax number When you request this review, you should state the reason(s) you believe the claim was improperly denied and submit for review any pertinent documents, including but not limited to, additional medical or vocational information and any facts, data, questions or comments you deem appropriate so that Claim Administrator may give your appeal proper consideration. The appeal review determination will be made by Claim Administrator, ordinarily no later than 45 days after receipt of a request for review, unless special circumstances require an extension of time for processing the appeal. If special circumstances require more time to consider an appeal, the Claim Administrator Appeals Unit may take up to two periods of 21 days each to reach a decision. If this additional time is needed, the Appeals Unit will notify you in writing by mail before the initial 45 day period has expired. Claim Appeal Procedure - Final If Claim Administrator denies your Short-term disability claim for benefits on appeal, you have 30 days from the date of receipt of the written notification of denial to appeal to Claim Administrator for a final determination under the Claims appeal procedure. Requests for review of a final appeal should be sent to Claim Administrator at P.O. Box 14446, Lexington, KY , or fax number The final appeal decision will be made by an appeal committee at CPS. Claim Administrator will facilitate the process of receiving the appeal and submitting the information to CPS. CPS Short-term Disability Plan rev Page 13

14 When you request this final appeal review, you should state the reason(s) you believe the claim was improperly denied and submit for review any pertinent documents, including but not limited to, additional medical or vocational information and any facts, data, questions or comments you deem appropriate so that your appeal may be given proper consideration. The final appeal review determination will be made by an appeal committee at CPS, ordinarily no later than 45 days after receipt of a request for review, unless special circumstances require an extension of time for processing the appeal. If special circumstances require more time to consider an appeal, the Claim Administrator Appeals Unit or CPS may take up to two periods of 21 days each to reach a decision. If this additional time is needed, the Appeals Unit will notify the you in writing by mail before the initial 45 day period has expired. The decision made by the CPS appeal committee on all Short-term disability appeals is final and binding. CPS Short-term Disability Plan rev Page 14

15 Rights of Restitution and Reimbursement and Subrogation If the Short-term disability plan provides or pays benefits as a result of a disabling injury or sickness: Caused by the act or omission of another party; Covered by Workers Compensation; For which no-fault or employers liability laws also provide coverage; Sustained on the property of a third party that has premises liability insurance available, then: CPS, or the Claims Administrator on behalf of CPS, has an equitable lien on any moneys that might be owed to you for the injury or sickness as well as the equitable right to recover the value of services and payments made under the Short-term disability plan. This right is by restitution and reimbursement or subrogation, and exists because the benefit payable under the Plan is the net amount of covered claims after taking all other forms of recovery into account. The right of restitution and reimbursement means that the Short-term disability plan has a lien on any recovery that you become entitled to receive. Accordingly, if you receive benefits under any of the circumstances listed, you must repay the Short-term disability plan the amount of the benefits you receive from another source up to the amount you have received from the Short-term disability plan because the plan has an equitable lien in that amount. Recovery includes all amounts received by you from any persons, organizations or insurers by way of settlement, judgment, and award or otherwise on account of such injury or sickness. The right of subrogation means that CPS, the Claims Administrator or another third party acting on behalf of CPS may make claim in your name or CPS's name against any persons, organizations or insurers on account of such injury or sickness. The rights of restitution and reimbursement or subrogation apply whether or not you have been fully compensated for your losses or damages by any recovery of payments. If you settle a claim against a third party, you are deemed to have been made whole by such settlement so that CPS, or the Claims Administrator or other third party acting on behalf of CPS, is entitled to immediately collect the present value of its subrogation rights as the first priority claim from said settlement or judgment. CPS is entitled to the first dollars recovered. No attorney's fees may be payable from any subrogation recovery unless CPS has been notified of the attorney's proposed representation in advance, and unless CPS has agreed in writing to the representation of the CPS s interests by that attorney. Under certain circumstances, you will be required to hold CPS harmless against future benefit payments due to the injury or sickness for which a settlement is reached. These rights of restitution and reimbursement or subrogation apply to any type of recovery from any third party, including, but not limited to recoveries from tort-feasors, underinsured motorist coverage, uninsured motorist coverage, other substitute coverage or any other right of recovery, whether based on tort, contract, equity or any other theory of recovery. Any CPS Short-term Disability Plan rev Page 15

16 amounts you receive from such a recovery must be held in trust for the CPS s benefit to the extent of the Short-term disability plan's restitution and reimbursement or subrogation claims. You must cooperate fully with every effort by CPS, the Claims Administrator or other third party acting on behalf of CPS to enforce the CPS's rights of restitution and reimbursement or subrogation. Access to Records By filing a claim for benefits under the short-term disability plan, you authorize the CPS and Claims Administrator and their representatives (collectively the "Administrators") to have access to any health records or medical information held by any health care provider and employment information held by any employer. You also authorize the Administrators to use your health records, medical information and employment information for claims processing (including, without limitation, claims for restitution and reimbursement or subrogation under the Short-term disability plan), disability claims data evaluation, and evaluation of potential or actual claims against the Administrators. Recovery of Benefits CPS, on its own behalf or through the Claims Administrator or another third party administrator, has the right to recover any benefit payments that are made in excess of the amount you are eligible to receive under the Plan, including but not limited to: Erroneous payments, Payments made for any periods for which you fail to provide satisfactory evidence of a covered disability, or Payments not reduced by amounts you receive from a source listed under "Reduction of Benefit Payments." Retroactive payments from any source listed under "Amount of the Benefit You Receive Reduction of Benefit Payments" must be immediately disclosed to the Claims Administrator. Excess payments will be recovered directly from you, or if necessary, from future benefit payments or from your estate, to the extent permitted by law. CPS Short-term Disability Plan rev Page 16