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Service Employees 32BJ North Health Fund
Tri-State Preferred North Summary Plan Description (SPD) >> Statutory Short-Term Disability Benefits
The following is a summary of your statutory short-term disability
benefits. For more detailed information or if you have questions, contact
The First Rehabilitation Life Insurance Company of America (First
Rehabilitation) or the Fund office.
Eligibility
The Fund provides statutory short-term disability benefits to participants
who are covered by the BRAB (Bronx Realty Advisory Board) contract and
others whose employers have opted to provide statutory short-term disability
through the Fund. Contact the Fund office at 1-914-637-7000 to determine
whether you are covered by the Fund. If you are not covered by the Fund, you
should contact your employer.
Participant Only
Statutory short-term disability benefits are provided through First
Rehabilitation.
Statutory short-term disability benefits are temporary cash benefits paid to
an eligible wage earner, when he/she is disabled by an off-the-job injury or illness.
Statutory short-term disability benefits are also paid to an unemployed worker to
replace unemployment insurance benefits lost because of illness or injury.
Statutory short-term disability benefits are paid by First Rehabilitation to
an actively working participant whose collective bargaining agreement provides
for the provision of such benefits and who becomes disabled to the extent he/she
can perform none of the usual and customary duties with his/her employer.
Procedural Conditions
The following procedural conditions apply to statutory short-term
disability benefits:
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If you are currently employed, or if you have been unemployed for
less than four weeks from the date your disability began, a white DB-450
form must be completed and received by First Rehabilitation within 30
days from the beginning of the disability. This form may be obtained from
the Fund Office, First Rehabilitation or online at www.FirstRehab.com.
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If you have been unemployed more than four weeks from the date the
disability began, a green DB-300 form must be completed and received by First
Rehabilitation within 30 days from the beginning of the disability. This form
may be obtained from the Fund Office, First Rehabilitation or at www.FirstRehab.com.
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You must file your claim within 30 days after you become disabled.
If you file late you will not be paid for any disability period more than two
weeks before the claim is filed. Late filings may be excused if it is shown
that it was not reasonably possible to file earlier. Benefits will not be paid if
you file more than 26 weeks after your disability begins.
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Supplemental forms are sent to the participant as needed by
First Rehabilitation and must be returned within two weeks of the date
sent by First Rehabilitation or by the due date listed on the form. If the
supplemental form and any requested documentation are not returned on
time, you will not receive any additional statutory short-term disability
benefits for that disability.
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Your disability must be verified in writing on the claim form by a
physician, chiropractor, podiatrist, psychologist, dentist, or certified nurse
midwife in order to qualify for benefits. You must be seen by one of the above
health care providers either in his/her office, at your home, or at the hospital.
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If you are dependent for healing upon prayer through spiritual
means alone in the practice of religion, you must be under the care of a
duly accredited practitioner to qualify for the benefits. In this situation,
the practitioner must complete and sign the “Practitioner’s Statement”
(Form 450.5). This form may be obtained from the Fund Office, First
Rehabilitation or www.FirstRehab.com.
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All questions on the claim form must be answered. Incomplete
forms will be returned for completion. Forms may be mailed or faxed to
First Rehabilitation at 1-516-829-8211 (see the "Where to Send Claims Forms" section).
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Statutory short-term disability will not be considered as beginning
more than three days prior to the first visit to a physician during the
disability period. Telephone consultations will not be accepted. Payments
will begin as of day eight (8) of disability.
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If you are filing for statutory short-term disability and have a
claim with sources besides the Fund (i.e., Workers’ Compensation or auto
insurance) you must still file statutory short-term disability claim forms.
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Voluntary termination of employment may affect your right
to statutory short-term disability benefits. If you are disabled due to
pregnancy, you may be entitled to up to 26 weeks of benefits. Disability can
occur anytime during pregnancy. Disability can only be determined and
certified by a physician or certified nurse midwife through the submission
of medical reports. If you become disabled more than four to six weeks
prior to the anticipated birth date, or you are disabled more than for the
six weeks after the actual birth date, more detailed information regarding
the disability may be required.
Limitations
The following limitations apply to statutory short-term disability benefits:
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Benefits are not payable if the disability is due to an accident or
sickness:
• Sustained on any job (if you have a Workers’ Compensation
claim
you should notify your employer immediately)
• Caused by an act of war
• Self-inflicted
• For which some other person or entity pays or is responsible
• Sustained in the commission of a felony or willful misconduct
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Benefits are payable when employee is on vacation. An employee
may not receive statutory short-term disability benefits when she/he is
collecting sick pay.
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In some instances, a member can recover and re-file for statutory short-term
disability. Contact First Rehabilitation or the Fund Office for details.
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A white DB-450 form must be filed for any recurrence of a
disability regardless of the length of time you returned to work.
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Lack of knowledge of coverage does not excuse these requirements.
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If a QMCSO (see the "Assignment of Plan Benefits" section) is received directing that statutory
short-term disability benefits be paid to satisfy a participant’s child
support obligation, and benefits are currently payable or become payable
while the QMCSO is in effect, payments will be made to either the state
agency or alternate recipient listed in the QMCSO.
When Benefits Begin and End
Benefits begin on the eighth day that you are unable to work due to a
non-occupational illness or injury. Benefits are payable for up to 26 weeks
in a 52 consecutive week period.
Amount of Benefits
The weekly benefit amount is equal to one-half of your average gross
weekly earnings (up to a maximum of $170.00/week, to a maximum set by
statutory guidelines) during the eight weeks prior to the start of your disability.
Benefits Exhaustion
Although your eligibility for health benefits continues while you are
receiving statutory short-term disability benefits, as stated in the "Eligibility and Participation" section, your eligibility under the Plan ends on the earlier of when you
have completed 26 weeks of statutory short-term disability or Workers’
Compensation, for a period during which employer contributions were
required, or when you have exhausted your benefits under statutory
short-term disability or Workers’ Compensation for a period during which
employer contributions were required.
Tax Issues
First Rehabilitation will send the Fund a W-2 form reporting the total
benefits paid in a calendar year. The Fund will forward the W-2 to the
employer and a copy will be sent to the Internal Revenue Service. Contact
your employer for further information regarding possible tax consequences
including Social Security tax, Medicare tax and Federal unemployment taxes.
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