Long-Term Disability Insurance: Claims Process

Purpose

This document describes the process, including required forms, for filing a long-term disability claim.

Initiating a Claim for Long-Term Disability Benefits

Employees on New York State Disability are monitored on an on-going basis by central office and First Reliance Standard Life Insurance (First Reliance) to determine the potential for, and the employee's eligibility for, long-term disability benefits (disability exceeding six months).

Process

The process for filing a long-term disability claim contains the following steps:

  1. Central office sends a cover letter and a First Reliance Benefits Application to the employee.
  2. Employee and physician complete required forms and returns them to First Reliance.
  3. Central office completes Employer Statement and submits it to First Reliance with a copy of the employee's job description.
  4. First Reliance makes the claim determination.

Letter and Application

After an employee has been disabled for four months, central office sends a letter and First Reliance Benefits Application to the employee. Operating locations will receive a copy of correspondence sent to the employee.

Letter

The letter contains the following information:

First Reliance Benefits Application

The application contains the following:

Required Forms

The following table describes the steps taken by the employee and his or her attending physician to complete and submit all required forms.

Step

Who Does It

Action

1

Employee

Completes and signs the Employee Statement, Benefits from Other Sources, Authorization for Release of Information, and Repayment Understanding Agreement.

2

Employee

Submits the application to his or her attending physician and asks the physician to complete and sign the Attending Physician's Statement.

Note: First Reliance may request an independent medical examination at no cost to the employee.

3

Physician

Completes the form and sends it to First Reliance.

4

First Reliance

Notifies the benefits administration unit in the Office of Human Resources at central office when the completed forms are received.

Employer Statement

The Employer’s Statement provides proof of the employee’s eligibility for long-term disability insurance, salary information, and a description of any other disability benefits available to the employee.

Once First Reliance notifies central office that an application has been received and central office has obtained the employee's job description from the operating location, an original, completed Employer's Statement and a copy of the job description are submitted to First Reliance.

Claim Determination

First Reliance reviews the claim and provides the employee with written claim approval or disapproval within 105 days from the day the application was submitted. If the claim is approved, a check is sent to the employee by First Reliance each month while the disability continues.

First Reliance will estimate the employee's Social Security disability benefits and reduce the long-term disability benefits by that amount, until a written notice of benefits is received from the Social Security Administration.

Note: First Reliance and Social Security claim reviews are performed independently from one another in establishing the eligibility for disability benefits.

Refer to Benefits Provided Under Long-Term Disability Insurance for information about Social Security waiting periods and obtaining the benefits.

Monitoring Disability Claims

A medical review of each case is performed at intervals appropriate to the nature of the disability (i.e., three months, six months, or annually). During the medical review, First Reliance requests that the physician send copies of the employee's medical records that provide proof of continuing total disability.

When a Claim is Denied

If the claim is denied, First Reliance notifies the:

Note: Long-term disability claims can be initially approved, and subsequently denied, during any of the claim's periodic reviews.

The employee has the right to appeal if denied. Instructions for appealing are included in the denial letter sent from First Reliance.

Change History

 

 

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