Short Term Disability Disputes

One of the benefits many employers provide to their employees is disability benefits. These are typically covered by a private insurance company, but sometimes the employer funds them itself. The purpose of the benefits is to replace income lost by an employee due to the inability to work because of a disability.

What qualifies as a disability? In employment law terms, a disability is a medical condition that prevents a person from working for some time. Unable to work, the employee loses income. Depending on the condition, the disability benefits provided by the employer or insurance may cover all or some of the lost income. It may also cover other medical expenses.

In the employment context, disabilities are categorized as either “short-term” or “long-term.” Examples of long-term disabilities include:

• Illnesses lasting for many months or longer
• Chronic conditions
• Conditions that recur over time
• Serious emotional or mental illnesses

Specific insurance companies and state disability programs may maintain different criteria for determining what constitutes a long-term disability as opposed to a short-term disability. State laws may also vary in terms of disability definitions and applications.

A short-term disability is any temporary disability, with the expectation that the injured or sick employee can return to work after a recovery period. Short-term disabilities are usually moderately serious and non-life-threatening injuries or illnesses. Some examples of conditions or injuries that could constitute a short-term disability include:

• Sprains or muscle strains
• Injuries that require surgery
• Minor fractures or broken bones
• Injuries specified in the insurance policy as short-term
• Various kinds of on-the-job injuries

On-the-Job Injuries

Generally speaking, for an injury to be considered an “on-the-job injury,” it must arise out of the employee’s work and occur while the employee is engaged in work for the employer. This means the injury must have happened at the worksite while the employee was on the clock.

There are three classifications of on-the-job injuries:

1. Specific events: Specific events are a one-time event or trauma, such as when a construction worker falls off of a ladder
2. Cumulative trauma: Cumulative trauma is caused by repetitive movement or work, such as developing carpal tunnel syndrome due to excessive typing or losing hearing as a result of working with very loud machines
3. Occupational disease: Occupational diseases are illnesses caused by being exposed to substances at work, such as lung disease caused by asbestos exposure

What Is the Difference Between Total vs. Partial Disability?

Sometimes, short-term disabilities may involve only a partial disability. Partial disability is an injury or illness where the employee can work part-time or in a related position. Such disabilities are commonly due to an on-the-job injury or a moderately serious illness.

On the other hand, a total disability is one in which the employee is prevented from performing any work at all because of the injury or condition. Examples of total disability include:

• The loss of two limbs
• Paralysis
• Chronic pain
• Blindness
• Impairment due to a serious occupational disease.

Can I Receive Benefits for Short-Term Disability?

Depending on the circumstances of each specific situation, it is possible to receive benefits for short-term disability. Generally, short-term disability is covered by the employer or through private insurance companies. Employees are also sometimes provided with the option to purchase their disability packages.

Most state and federal social security disability insurance programs only cover long-term or permanent disabilities. However, there are five states which maintain laws requiring employers to provide some form of short-term disability options. These states are California, Hawaii, New Jersey, New York and Rhode Island. Short-term disability benefits typically include paid time off and some reimbursement for lost wages.

In terms of collecting disability payments or damages awards, there are significant differences between total and partial disability. For those experiencing partial disability, the legal remedies most commonly include compensation for lost wages due to the injury.

Total disability will also result in compensation for lost wages. Because a person with a permanent total disability cannot work at any job, additional damages may be awarded for issues such as the loss of future earnings or lost earning capacity. In especially serious cases, loss of future earnings may be claimed for a partial disability.

What If I Have a Dispute Over Short-Term Disability Issues?

One of the most common and important disputes regarding short-term disability would be the denial of benefits. Claims are generally denied for one of three reasons:

1. The insurance policy does not cover the applicant’s condition. Some policies offer benefits for specific conditions but not for others
2. There was not a sufficient amount of medical evidence provided along with the application for benefits
3. The insurer or other party providing short-term disability benefits denied the claim because they believed the claimant was lying about their condition.

Denials may sometimes be appealed. In the case of short-term disability benefits, applicants receive protections under “ERISA“, the Employment Retirement Income Security Act. This federal law governs pension, benefits, and retirement for private sector employees. Under ERISA, there is a set process for appealing denials.

The appeals process is as follows:

• Review the denial letter: If your short-term disability claim has been denied, you will receive a letter stating so and giving a reason. You should carefully review this letter to determine why your claim was denied. The letter will also describe how to proceed with an appeal and what deadlines you must meet.
• Review your policy: If your denied benefits were to come from an insurance policy, it is important to carefully review this policy before moving forward. There may be language contained within the policy that prohibits you from taking certain actions. Becoming intimately familiar with your insurance policy will reduce the possibility of making mistakes that could negatively impact your case.
• Request your administrative record: Your administrative record consists of the medical records and any other evidence you provided to the insurance adjuster or the party responsible for reviewing your claim. You will want a copy of this record to supplement it with additional evidence, as this is the only information that may be considered during the formal appeal.
• Submit a written appeal: Generally speaking, an appeal must be in writing; it cannot be as simple as a phone call to your insurance company. Your written appeal should detail all factual legal arguments you have against their denial.

The appeals process can be complex and requires knowing how and when to submit what kind of evidence. If you are denied short-term disability benefits, you should consult an attorney specializing in short-term disability benefits. Disputes may involve multiple parties, such as employers and third-party insurance providers. The involvement of multiple parties further complicates the issue. The appeals process is complicated, and an attorney can help you complete the necessary steps.

Do I Need a Lawyer for Help with Short-Term Disability Issues?

You should consult a local workers’ compensation lawyer if facing any disability or employment issues. Because disability laws vary from state to state, an experienced and local employment attorney would be best suited for understanding your state’s laws and how they will apply to your case. An attorney can also help you with filing a claim or an appeal. Finally, an attorney can represent you in court as needed and ensure that your legal rights are protected.