How an employer or its agent defines the term "disability" can determine whether an employee will receive paid or unpaid leave when she is unable to work or whether the claim will be denied . However, most policies let you appeal decisions made by your employer or privately managed programs.
Employer Sponsored Disability Programs
If your employer offers you the option to purchase short-term and long-term disability insurance or provides this coverage as part of your compensation package, claim decisions generally are not made by the business. Instead, they are made by an outside insurer that provides the policies and processes the claims. These plans are regulated by state laws that dictate the minimum requirements for appeals and the amount of time an insurer has to review your appeals documents. If the plan denies your final appeal under the terms of your policy, you may seek a judicial review of the decision.
FMLA Leave for Disability
Public employees and private sector employees of businesses with at least 50 workers who worked for at least 20 weeks are covered by the Family and Medical Leave Act. The FMLA requires employees up to 12 weeks of unpaid leave to receive medical treatment for both emergency and chronic conditions. Pregnancies are included. If you have a disability requiring periodic treatment, you may take FMLA leave for visits not covered by your employer's polices.
FMLA Leave Denials
When you first submit a request for FMLA leave, your employer may request a medical certification. If your employer questions the validity of the certification, he can order a second or third medical opinion at the company's expense. If both the second and third opinion state that no serious condition exists, your leave request can be denied. An employer may also deny FMLA leave when you fail to provide adequate notice, usually 30 days, if the need for care was foreseeable. For example, if you schedule a surgery for May 30 on April 15, you must offer your employer notice on May 1. When an emergency occurs, provide notice as soon as possible.
Social Security Disability
The Social Security Administration has its own criteria for determining eligibility for Social Security Disability Insurance, or SSDI. If you were not approved for disability payments through private insurance purchased through your employer, you may still qualify for SSDI benefits, particularly if your private claim was dismissed based on filing errors or a technicality. Employers have no input in the decision making process. If your claim is denied by the SSA, you may appeal through both the administration and a judicial review process.
- Massachusetts CFIDS/ME & FM Association: Disability Insurance Claims: General Information
- U.S. Department of Labor: Filing a Claim for Your Health or Disability Benefits
- U.S. Department of Labor: FMLA Frequently Asked Questions
- Disability Planner: How We Decide If You Are Disabled
- HR Morning: FMLA: Second Opinion Not Enough to Reject Leave
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