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disability insurance claim

Frequently Asked Questions About California Disability Insurance

Posted on February 15, 2017 in Employment Law

Many workers in California may experience a tragedy in their life. It could result in them being unable to work. The victim of an unforeseen accident may not be able to earn enough income to survive. To avoid this situation, California has a State Disability Insurance (SDI) program designed to provide wage replacement benefits to individuals in California who are not able to work because of injury, illness as well as pregnancy. Over 17 million workers in California are covered by this program.

What is Defined as a Disability?

According to the state of California, a disability is some type of injury or illness that is either mental or physical. It results in a condition that prevents an individual from engaging in regular and customary duties at their job. This covers a number of things including pregnancy, elective surgery and a variety of other medical conditions. Disability Insurance pays benefits for illness or injuries relating to work under specified circumstances defined by law.

Who Is Eligible For Disability Insurance In California?

A person can collect disability insurance if they are unable to perform their required job duties for a minimum of eight consecutive days. A person should be employed or be actively seeking employment when the disability occurred. An individual must experience a loss of income resulting from the disability.

A person must have had a minimum income of $300 from which deductions for California’s disability insurance were taken during the previous employment period. A person seeking disability insurance payments must be receiving treatment and care from a licensed physician or accredited practitioner of a religion.

Individuals seeking disability insurance payments must also file a claim within 49 days of the date of becoming disabled. A physician is required to complete a portion of the form that gives medical certification of disability.

How are You Covered by Disability Insurance in California?

In California, employees are covered by disability insurance by paying premiums through payroll taxes. Anyone who is self-employed can also be eligible to participate by paying for elective insurance coverage. Their premiums will be based on a self-employed person’s profits from their previous year. Most workers in California are covered by disability insurance through their employer. Some groups of employees are not covered. They are covered by a separate version of disability insurance. This includes interstate railroad workers, certain non-profit workers, some domestic workers as well as most individuals who work in government.

How Long is the Benefit Period?

This will be determined by the statement given by a medical provider explaining the length of time a person will be disabled. It is possible for a medical provider to extend the time a person receives disability payments to the maximum permitted by law. This is approximately 52 weeks.

Should a person go back to their job on a part-time basis or have another source of income, it’s possible their benefit period could last longer than 52 weeks. It is possible in some situations for an individual to remain disabled at the end of their benefit period. When this occurs, a person becomes eligible for long-term disability insurance coverage.

Is Short Term Disability Mandatory in California?

The State of California does require all employees to pay into the short-term disability insurance program, and this is done through payroll deductions. However, if an employee finds that they are unable to continue working due to some kind of covered disability, then they can begin to collect weekly benefits through the program until they have recovered. At that time, they will then continue to pay for the benefits as usual through payroll deductions.

Is Alcohol and Drug Rehabilitation Covered Under Disability Insurance?

If you must enter a rehabilitation center for alcoholics, then it is possible that you may qualify for up to thirty days of disability insurance benefits while you are an active resident of an approved rehabilitation center. However, if your physician feels that you need an additional thirty days in rehab, then they may be able to certify this so that you can receive an additional thirty days of benefits.

When it comes to drug addiction, however, you may be entitled up to forty-five days as opposed to thirty and the same extension applies for the drug rehabilitation center as it does for the alcohol rehabilitation center. As long as the physician certifies that you need to continue your care in the approved facility, you may be eligible for the additional forty-five days of benefits.

However, if the judge ordered you to check into a drug and alcohol rehabilitation center as a way to avoid jail time, then you cannot receive any benefits under the state’s disability insurance program. This is due to it being the result of a criminal violation.

How Can I Prevent and Report Disability Insurance Fraud in California as an Employer?

If you are an employer or owner and you suspect disability insurance fraud, there are a couple of ways you can submit a Fraud Reporting Form. You can submit the form online, or you can call an anonymous tip into the Fraud Tip Hotline at 1-800-229-6297.

Fraud can take the form of many things including someone claiming to be an employee when they are not, a past employee that has been terminated, laid off, or has quit, or if the person filing for disability insurance is an employee that is continuing to work and is still receiving wages.

Additionally, keep in mind that you should also check if they have already filed for a worker’s compensation claim, if they are incorrectly using their social security number, or if they are working illegally under a fraudulent name.

How Can I Prevent and Report Disability Insurance Fraud in California as a Physician?

If you are a practitioner or physician that suspects disability insurance fraud in California, then you should immediately report your findings. Is the patient no longer under your care? Have they recovered from their disability? Additionally, other signs of fraud can include the same factors as the employer may experience such as fraudulent names and social security numbers or open and active workers compensation claims that have already been filed.

How Do I File A Disability Insurance Claim In California?

The state of California tries to make it as easy as possible to file a claim. The process normally starts when a person’s employer or health care practitioner provides them with the necessary form. This form can also be obtained from California’s Economic Development Department (EDD) website. There is a certain portion of the form a person must complete. Their health care practitioner is responsible for filling out the rest of it. The next step is for the EDD to contact a person’s employer and confirm wages, length of employment and more.

The EDD will call or try to contact a person should they have any questions about the information provided. They can answer questions and give a disability insurance explanation if necessary. Should a person qualify for disability benefits, the EDD will send a notice informing them they’re eligible. This notice will also provide information on anticipated benefit amounts and when they should begin receiving benefits.

Eligible individuals will receive benefits once every two weeks. It is important people know that any information they provide on their claim form is protected under Health Insurance Portability and Accountability Act (HIPPA). When forms are sent online, the data is encrypted in transit. It is always stored in a way to make certain confidentiality is maintained.

What Is A Typical Claim Amount?

A person in California who is approved to receive disability insurance payments will receive around 55 percent of their usual wages. There is a cap on the amount a person will receive. California will determine the amount a person receives using a base period. In most situations, this is the 12 month earnings period prior to the last complete calendar quarter a person was employed prior to being disabled.

Could I Experience Benefit Reductions?

The amount of benefits a person receives could be reduced for a number of reasons. This includes part-time work, military pay, bonuses, worker’s compensation payments, holiday pay and any other type of income. Depending on a person’s individual situation, a number of these could apply.

What if My Work Schedule Has Been Reduced or I am Only Working Part Time?

One of the most commonly asked questions regarding disability insurance in California is if they can still file a claim if they are still working but are experiencing a shortage of hours due to their disability. Yes. If you are experiencing a loss of wages resulting from your disability, then you can file a claim for benefits.

If you don’t work full time and are rather employed part-time, you can also still apply for benefits if you are making a minimum of $300 in gross wages and you meet all the other requirements for disability insurance eligibility.

Also, you should note that even if you are receiving disability insurance benefits, you can still collect any vacation or sick pay you have already accumulated through your employer. The benefit types do not interfere with each other.

What Disability Plans are Available?

The following are a few of the disability plans that are available in California:

State Plan: this plan is offered to employees of the state if they find they are unable to work and will experience lost wages due to a non-work related illness, an injury, or pregnancy. These benefits are administered by the Employment Development Department (EDD), and the State Controller’s Office is who calculates and withholds the deductions for these benefits.

Voluntary Plan: this is a plan that may be offered by your employer rather than the SDI coverage you could qualify for through the state. As long as you have coverage under this voluntary plan with the employer, you will not be eligible for any other disability benefits through the state of California.

Elective Coverage: this plan is available to those who are not employees and are rather self-employed, independent contractors, small business owners, and entrepreneurs. To be eligible for this coverage, you must own a business or be self-employed, make at least $4600 in revenue each year, and be able to operate on a full-time basis alongside other more specific requirements to determine eligibility.

Is there Coverage Available if I am Self-Employed?

Elective coverage is available for those that are currently self-employed. The SDI coverage, in this case, includes both Disability Insurance and Paid Family Leave benefits. To file for this coverage, you must submit the request in writing and file it with your approved Employment Development Department. The coverage will remain in effect for up to two years unless termination is required due to the different criteria being met.

What To Do If You Have A Potential Case Related To Disability Insurance Claims

If you believe that you have a case, you should contact a San Diego attorney right away. If you would like someone to review your case today, send us an email or call Walker Law at (619) 839-9978 to schedule your free consultation.

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