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Company provided STD

Discussion in 'Medical Leave & Disability' started by Ismail Al, Jul 26, 2020.

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  1. Ismail Al

    Ismail Al Law Topic Starter New Member

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    Jurisdiction:
    New York
    STD Policy , involuntary separation
    Due to serious Neck condition I applied to company provided STD. Insurance company denied the claim because short after I applied to the STD I was terminated.They said because I was terminated my coverage ended .
    The STD policy about termination is below :"When Benefits End. An employee will no longer be considered eligible for STD benefits if or when he or she:
    Separates from the Company (e.g., resigns, moves to a Company subsidiary, retires, dies)" .
    It doesnt mention anything about involuntary termination. Does the term "seperates" cover involuntary termination?
    I have 2 weeks to appeal. Can I appeal this ?
     
  2. adjusterjack

    adjusterjack Super Moderator

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    Yes.

    The notation "e.g." (exempli gratia) means "for example." The examples in parentheses are not all inclusive, they are just several examples of separation but is not a complete list of the methods of separation.

    However, it occurs to me that if you were eligible for coverage on the day you applied then coverage should have been effective prior to your termination and you would have been on disability instead of being terminated.

    And if you were terminated because you applied for disability there may be a wrongful termination claim available to you.

    I suggest you have an attorney look at your policy and advise you accordingly.
     
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  3. cbg

    cbg Super Moderator

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    "Separates from the company" means you don't work there any more. It covers all reasons for termination unless one type of separation is EXcluded. It does not have to list all possible ways of separation; unless the policy says, "Separation does not mean..." then it means everything.

    Most STD policies have a waiting period before it applies. By that I mean if you are injured on the first of the month, benefits do not begin until the 8th of the month or even the 15th of the month, and then are payable according to the policy after that. If you were terminated during that waiting period, it is likely - not definite, but likely - that the policy would not apply.

    If you post the exact wording of the policy definitions for who is eligible and when coverage is excluded, I could probably save you the cost of an attorney.
     
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  4. Ismail Al

    Ismail Al Law Topic Starter New Member

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    Thanks for responding.
    I am adding some more details that may be helpful:
    I have been discriminated at this job since beginning, My manager was very incompetent and has been always making false statments about my performance,
    they signed a poor performance review in March. They gave me short term goals and to complete those I had to work extremely and due to that I developed this disability ,
    I applied to STD in late April and I took a week off . My neurosurgeon signed 2 months disability at that time.

    I complained to HR about the false statements in the review and they changed my manager same day. In early May new manager started to take over my group.
    So I returned to work after using 5 sick days to complete a critical project despite serious pain , I hoped I could work out with the new manager.

    Later I didnt want to lose my STD right and I re-applied to STD in Jun and 2 days later I was terminated.
    So I used total of 7 sick days before my second STD application which is more than Elimination period. (The elimination policy of STD is 5 days.
    )
    The Metlife's decline letter is at the bottom .


    The wording of when the policy ends is below:

    When Benefits End. An employee will no longer be considered eligible for
    STD benefits if or when he or she:
    (1) Is no longer disabled, as determined by the Claims Administrator.
    (2) Is no longer under the ongoing care of a physician or is no longer
    receiving appropriate care and treatment.
    (3) Is no longer continuously complying with the requirements of such
    appropriate care and treatment.
    (4) Fails to provide forms and/or information requested by the Claims
    Administrator.
    (5) Refuses to be examined by an independent physician or a licensed
    and certified health care professional as requested by the Claims
    Administrator, who has the right to require an examination or
    evaluation of an employee, at no expense to the employee, at any
    reasonable time while a claim is pending or payable.
    (6) Is not considered disabled by the Claims Administrator, based on an
    independent medical exam report or functional capacity evaluation.
    (7) Has exhausted 25 weeks of STD benefits (Reference EXHIBIT A).
    (8) Refuses to discuss with the Company and/or refuses to accept
    reasonable accommodations regarding work arrangements that
    would enable the employee to return to work.
    (9) Is no longer a participant in STD benefits because the Company has
    ended or amended the program.
    (10) Commits any fraudulent act in connection with a claim.
    (11) Is confined to a penal or correctional institution.
    (12) Separates from the Company (e.g., resigns, moves to a Company
    subsidiary, retires, dies).

    SUBJECT
    ADMINISTRATION OF COMPANY SICK TIME AND
    SHORT-TERM DISABILITY BENEFITS—
    MANAGEMENT EMPLOYEES
    DATE NUMBER SUPERSEDES PAGE 7 OF
    Sep 30, 2019 CI-560-2 CI-560-2
    Jun 5, ‘17 15 PAGES
    (13) Performs work at any other paid employment or self-employment
    (including any dual employment that was authorized prior to the
    disability absence) during a period in which the employee is
    receiving STD benefits

    The decline response from STD company is below

    upload_2020-7-26_16-26-19.png
    Thanks again
     
  5. cbg

    cbg Super Moderator

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    Okay. Now post the description of who IS eligible.
     
  6. Ismail Al

    Ismail Al Law Topic Starter New Member

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    4.0 GENERAL PROVISIONS --
    4.1 Employees are expected to report to work in accordance with their schedule.
    When an employee is unable to report to work because of his or her medical
    condition, he or she may be eligible for sick time or STD benefits as set forth in
    this Instruction.
    4.2 Employees who are sick or injured and unable to report to work must call the
    Voice Response Unit (VRU) at 1-800-409-7425 for the first five consecutive
    workdays of their absence (unless otherwise instructed by the employee
    wellness group) and must notify their supervisor prior to their scheduled start
    time or workday if requested to do so. Employees must follow the VRU
    instructions to report a new or continuing absence. A call made to the VRU after
    6:00 p.m. counts as registering a sick absence for the next calendar day.
    4.3 If a management employee has worked more than four hours during a workday
    and goes home sick for the remainder of that shift, the entire workday should be
    considered and coded as worked. No VRU call is required for the partial day
    worked since no sick time will be coded for that date. “Sick” coding should begin
    on the next consecutively scheduled work day. If the management employee
    has worked less than four hours during a workday and goes home sick for the
    remainder of that shift, the entire workday should be considered and coded as a
    sick day and a VRU call is needed.
    4.4 In the event that an employee cannot call the VRU or his or her supervisor to
    report a sick absence, a designee may call on the employee’s behalf. The
    employee’s supervisor must then notify the appropriate employee wellness
    group, and a Nurse Case Manager will contact the employee’s designee to verify
    the employee’s condition.
    SUBJECT
    ADMINISTRATION OF COMPANY SICK TIME AND
    SHORT-TERM DISABILITY BENEFITS—
    MANAGEMENT EMPLOYEES
    DATE NUMBER SUPERSEDES PAGE 4 OF
    Sep 30, 2019 CI-560-2 CI-560-2
    Jun 5, ‘17 15 PAGES
    4.5 During a sick absence, an employee must be available to attend a medical
    appointment if requested to do so by the employee wellness group subject to
    paragraph 5.5. Sick time and STD benefits may be recovered if the employee
    fails to keep the appointment.
    4.6 Sick time benefits are subject to recovery if the employee fails to call the VRU in
    accordance with the provisions of paragraph 4.2 and does not justify the failure
    within two payroll cycles of the sick absence.
    4.7 The final determination regarding duty status and sick time benefits is at the sole
    discretion of the employee wellness group. The final determination regarding
    STD and/or FMLA benefits is at the sole discretion of the Claims Administrator.
    4.8 An employee does not earn additional sick time while out on sick leave or in a
    leave no-pay status.
    4.9 Sick time and STD benefits are subject to the medical certification and
    documentation requirements as set forth in paragraph 5.3. Employees who have
    filed a timely claim will be eligible to receive STD benefits while their claim is
    pending and under review by the Claims Administrator. If a claim is denied,
    employees will be required to reimburse the Company for any payments received
    for STD benefits. Overpayments will be reimbursed to the Company through
    future salary payments, appropriate payroll deductions, or deductions from
    vacation payments due to the employee.
    4.10 New hires and rehires have a six-month waiting period before becoming eligible
    for Company-paid sick time and STD benefits, but they may be eligible for
    statutory State Disability benefits.
    5.0 PROCEDURES --
    5.1 Sick Absence Benefits –
    a. STD. Employees may be eligible for STD benefits, after they have been
    absent for five consecutive workdays and documentation has been
    submitted to the Claims Administrator. If a STD claim has been denied by
    the Claims Administrator, employees have the option to use vacation time
    or a personal holiday for the absence. When documentation is approved by
    the Claims Administrator, STD benef
     
  7. cbg

    cbg Super Moderator

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    What was the date of your injury?
     
  8. Ismail Al

    Ismail Al Law Topic Starter New Member

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    Mid March
     
  9. cbg

    cbg Super Moderator

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    When did you submit your STD claim? Were any benefits paid at any time?
     
  10. Ismail Al

    Ismail Al Law Topic Starter New Member

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    Late march
    I submitted first claim on Apr 20th week . It was denied stating that I returned to work on 6th day.
    I didnt get any STD benefits any time
     
  11. cbg

    cbg Super Moderator

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    And did you return to work after 6 days?
     
  12. Ismail Al

    Ismail Al Law Topic Starter New Member

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    I returned on the 6th day. Then take 2 more sick days in Jun
     
  13. Zigner

    Zigner Well-Known Member

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    It sounds to me like you're not eligible for STD benefits.
     
  14. cbg

    cbg Super Moderator

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    Based on my reading of the information you provided, I agree. You do not qualify for the STD benefits
     

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