General information

What is considered a disability? How is a disability different from an impairment?
The definitions of a "disability" and impairment" can differ among plans. Please consult your plan documents for the applicable definitions.

What is the difference between worker's compensation and disability benefits?
Worker’s compensation comes into play if an employee is injured at work. Disability benefits can be used when an employee cannot work at his or her regular job due to an illness or injury that occurs outside of work.

What is the difference between short term disability and long term disability?
For employees who become disabled and are unable to work, Aetna’s short term disability (STD) insurance benefits help them to meet financial responsibilities. Eligible employees generally receive an amount of base pay for up to 26 weeks of certified disability after a waiting period. The number of weeks that employees can receive STD benefits will vary by plan). The amount of base pay depends on an employee’s length of service at the time the disability occurs. STD checks are issued weekly.

Aetna also provides long term disability (LTD) insurance coverage. This provides a monthly benefit that is equal to 50 percent of an employee’s eligible pay. Employees may be eligible to receive LTD benefits after a 26-week period of certified STD. In addition to company-paid LTD benefits, employees may purchase an additional 10 percent of LTD coverage. This would provide 60 percent of his or her eligible pay. LTD checks are issued on a monthly basis.

What are the criteria for receiving short-term disability benefits?
We obtain objective medical findings to make sure an employee’s condition meets the definition of disability. The medical findings must indicate that he or she is not able to perform the material and substantial duties of their regular occupation. Your employee may be asked to assist us in obtaining necessary documentation. A note from the employee’s physician is not considered sufficient medical evidence.

How do STD insurance and LTD insurance work?
Each employee’s insurance benefits plan will differ. However, you should understand some common terms that you will see as part of a typical insurance plan:

• Benefit waiting period: The period of time that must elapse before benefits are payable under a group insurance contract.
• Self-insured: Some employers run their own insurance plans. They are call self-insured employers. A self-insured employer pays the insurance carrier to manage and administer an insurance plan. The employer pays all of its employees' claims. Some employers choose this option as a way to reduce costs.
• Fully-insured: A fully-insured plan is the traditional method of administering disability insurance. The employer allows the insurance carrier to both administer the insurance plan and pay all claims.

Which states have their own disability programs and how do employees contact them?

• California: Employee can call the local EDD office to obtain an application for benefits. The main number in Sacramento is 916-227-0220 or 800-480-3287.

California State Disability Insurance program

• Rhode Island: Employee can contact the State TDI office at (401) 222-3287 to apply for benefits.

Rhode Island State Disability program

• Puerto Rico: Department of Labor and Human Resources 787-754-2146
• New Jersey: Division of Disability Insurance Service at 609-292-2681
• New York: Workers' Compensation Board Disability Benefits Bureau at 518-474-6681
• Hawaii: Disability Compensation Unit at 808-586-9188

Do Social Security Disability Insurance (SSDI) and the American Disability Association (ADA) differ from an employer's disability plan?
Yes. To to be eligible for SSDI, an employee (the claimant) must:

• Have current insured status with Social Security
  • Have 40 quarters of coverage in order to be insured for SSDI.
  • Twenty of those 40 quarters must have occurred within 10 years of the date of disability.
• Meet Social Security's definition of disability
• Prove legal U.S. residency

According to the ADA, an individual has a disability if:

• He or she has a physical or mental impairment that substantially limits one or more of their major life activities.

Temporary impairments and pregnancy are excluded.

File a claim

When should an employee file a claim?
Your employees must file their claims by the third consecutive day of their absences. All employees who have a planned absence (such as a scheduled surgery) should file claims within the two weeks prior to their anticipated first day of absence.

What forms must be completed?
The employee must complete a Medical Release Form.

What is Aetna's role in processing the claim?
We accepts claim notification via toll free number, web-based customer portal or paper. During the initial intake, a member’s STD eligibility is verified. When members are identified as having both Aetna medical and Aetna disability coverage, IHD Secure Voice Authorization (HIPAA compliance) is performed during telephonic intake. A member’s consent is required for our IHD services. Paper and web claimants receive the HIPAA consent form in the mail. Additionally, during telephonic intake, the employee is educated about the claim process.

To ensure claims are properly prepared, our intake staff conducts a three-point contact. Three-point contact includes outreach to:

• The employee, to obtain any information not included in the initial claim submission
• The employer, to verify eligibility and confirm information about job duties
• The attending physician, to obtain disability-related medical information

When should pregnant employees file a claim with Aetna?
A pregnant employee may file her claim two weeks before her estimated delivery date. She may also file a claim if, for medical reasons, her doctor decides to take her out of the workplace before her due date.

How long does it take for a claim to be processed?
The claim process can take up to 14 calendar days for processing. Promptly completing the Medical Release Form will reduce the risk for delay.

What if Aetna's claims examiner doesn't receive the employee’s medical information from the treating physician?
Aetna will contact your employee for assistance in obtaining this information. It may include lab results, X-rays, reports and office-visit notes. If Aetna has not received the necessary medical information within 14 calendar days, benefits cannot be authorized. If this occurs, Aetna will send your employee a letter to notify him or her of what to do next.

What can an employee do if Aetna denies his or her claim?
We have an appeals process. If a claim is denied, the employee will receive a letter from a claims examiner that will explain the reasons for the denial. The letter also will describe the appeals process. The employee can contact the claims examiner for additional information.

Managing an employee’s disability

What are the roles and responsibilities of the manager or supervisor during an employee’s disability?
Educate your employees about their options in dealing with their disability and where they can find help. No matter what type of disability your employee is leaving on, (e.g. pregnancy, elective/planned surgery), a return to work plan should be put into place.