Table of Contents: Chapter 3
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310. SHORT-TERM DISABILITY 1/16/09
310.1. Definitions
"Plan Manager" refers to the City of Lee's Summit or their designated representative.
"Accidental Injury" is defined as bodily injury unrelated to work which causes a covered loss while the employee is covered by the Plan. The injury must result independently of disease, bodily infirmary or other cause.
"Active Service" refers to a Covered Person in active employment with the City of Lee's Summit, who is performing their regularly scheduled duties on a full-time basis, at their customary place of employment or at some location at which that employment required them to travel, or if they are absent from work solely by reason of vacation at the time their coverage would otherwise become effective. A Covered Person will be considered in Active Service on a day which is not a scheduled work day only if they were performing in the customary manner all of the regular duties of their employment on the last preceding scheduled work day.
"Claims Supervisor" means Insurance Specialist.
"Employee" means all active full-time employees who work a minimum of forty (40) hours per week at their customary place of employment.
"Grandfathered" means an employee who is totally disabled prior to July 1, 2009, will be eligible for benefits after earned sick leave is exhausted, on the first day after an accident or the eighth day of an illness. Other earned paid time off may be supplemented with short term disability payments up to a total of 100% of the employee's basic weekly earnings. When all earned paid time off is exhausted, no further sick or vacation accruals will be posted to the employee's banks while receiving short term disability benefits.
"Illness" means a bodily disorder, disease unrelated to work, or pregnancy which causes a covered loss while the Employee's coverage is in force.
"Maximum Period" means the maximum length of time the Weekly Benefit is paid, a combined total of 13 weeks including use of all paid time off.
"One Continuous Period of Total Disability" means an interval of time during which the employee remains disabled, beginning on the date of the first treatment for the disability.
It continues only while the employee is under the care of a physician who states in writing that the employee is disabled. A period of disability will be treated as part of aprior period (subject to the 13 weeks maximum benefit period) if the periods are due to the same or related causes and are separated by less than two weeks of return to Active Service.
"Physician" means a licensed physician who is acting within the scope of their license, or any other licensed practitioner required to be recognized for benefit payment purposes under the law of the state in which the employee lives and is acting within the scope of their license.
"Total Disability" and "Totally Disabled" mean, solely for purposes of Short-Term Disability coverage, the inability of the employee to engage, as a result of illness, in any occupation; however, in no event will an employee be considered to be totally disabled for any period of time during which such employee is not under the regular care and attendance of a legally qualified physician.
310.2. Benefits
The Weekly Benefit will be paid for each full week you are totally disabled. If benefits are payable for less than a full week, 1/5 of the Weekly Benefit will be paid for each day the regular employee is disabled. If benefits are payable for less than a full week to the Shift Employee, 1/7 of the weekly benefit will be paid for each day of disability. Benefits are paid at 60% of the employee's basic weekly earnings up to a maximum weekly benefit of $1,000 after all paid leave is exhausted. For exceptions, please see the definition of a grandfathered employee in this policy who is totally disabled prior to July 1, 2009.
310.3. Exclusions
No benefits are paid for disability resulting from (1) intentionally selfinflicted injury or attempted suicide, (2) commission of, or attempt to commit, a felony; (3) engaging in an illegal activity; (4) war or act of war, declared or undeclared; (5) participation in a riot; (6) a work-related injury.
310.4. Eligibility
Benefits are paid while disability continues or to the end of the Maximum Period, whichever is earlier. However, effective July 1, 2009, if the employee has 13 weeks of paid time off, s/he is not eligible for short term disability.
310.5. Sick and vacation accruals
The City will not apply sick and vacation accruals to the employee's banks while s/he is on unpaid leave and receiving disability payments.
310.6. Effective Date of Your Coverage
The effective date of your coverage is on the first day of the month following one complete calendar month of employment. If your effective date is a holiday or a day you are not scheduled to work, you will be considered in Active Service if you are not disabled on that day. If, due to disability or any other reason, you are not at work on your effective date, your coverage will be delayed until you are returned to Active Service.
310.7. Termination of Benefits
Payments will be terminated when the employee is able to return to work, a new certification by the physician has not been received, or the maximum benefit period of 13 weeks has been reached. At the end of 13 weeks, if the employee is still disabled, s/he may be eligible for Long-term Disability. Forms for this coverage are available in Human Resources.
Termination of Your Coverage
The coverage of any employee with regard to eligibility or benefits provided under this Plan shall cease on the earliest of the following dates:
12:00 Midnight the day in which termination of the eligible employee's employment occurs.
12:00 Midnight the day in which the employee fails to meet the Plan's definition of an employee.
12:00 Midnight on the date the Plan terminates.
12:00 Midnight on the date the employee is released to work.
310.8. Claim Payment Provisions
- 310.8.1. The City reserves the right to restrict or refuse coverage based on the evidence provided.
- 310.8.2. Any claim denied either in whole or in part may be appealed in writing to the City of Lee's Summit, Attention Human Resources Department. If your claim is denied, you will receive a written explanation referring to the Plan Provision on which the decision was based.
310.9. Administration
Benefits are funded through contributions made by the City of Lee's Summit.
- 310.9.1. Procedures for Filing Short-term Disability Claims
- 310.9.1.1. Eligibility Requirements:
Employee must have completed a full calendar month of full-time employment with the City of Lee's Summit.
Employee must be under the ongoing care of a Physician in the appropriate specialty as determined by the Plan Manager.
Employee must have reported their illness in a timely manner to their Supervisor, as required by departmental procedures and completed appropriate leave slips. The Supervisor will in turn monitor the employee's leave and inform the employee when s/he will be depleting his/her earned paid time off, thus qualifying the employee for Short-term Disability.
No benefits will be paid for any of the exclusions listed in the plan document.
Employee is required to report any changes in leave status and is not allowed to work for wage or profit for any employer during the Benefit Period.
Employee will be required to pay their portion of the health insurance premium during their period of disability. A claim form must be completed in its entirety if the employee is not eligible for Family Medical Leave. Claim forms are available in Human Resources. If unable to appear inperson to obtain a claim form, one may be obtained for the employee by a family memberor mailed upon request. Family Medical Leave runs concurrent with Short-term Disability.
The employee is responsible for getting the applicable Physician's Statement completed by the physician within 15 calendar days after the City requests the information from the employee.
- 310.9.1.2. Payment Process:
Taxes will be withheld according to the W-4 on file in Human Resources.
Short-term Disability Payments will be made only after proper documentation of disability has been received in Human Resources and approved by the Plan Manager.
Payments will be made by the City of Lee's Summit within two (2) weeks from the time the disability claim has been approved. The Claims Supervisor will notify the employee when the employee's claim has been approved or denied. Payments will be made bi-weekly, along with the City's regular payroll.
310.10. Appeal Process
Appeals must be made in writing within thirty (30) days after receiving notice of denial. Appeals should be addressed to the Claims Supervisor.
Appeals may include written comments or other items to support the employee's claim. The employee may review any non-privileged information that relates tothe request for review.
The Plan Manager will review the appeal claim when received. The employee will receive notice of the decision within 30 days after receipt of the request, or within 120 days if special circumstances require an extension.