How does short-term disability insurance work for surgery recovery?

A loss of income while you are out of work after a medical operation puts a dent in any family budget. Short-term disability may replace a portion of your wages while you heal.

However, the coverage works differently for each person. Many factors determine whether the insurance company or state program will approve your claim for benefits.

You will need to answer some of these questions first.

  • Do you have coverage in force before the procedure?
  • Will the operation trip the pre-existing condition exclusion?
  • Does the surgery qualify as a covered medical condition?
  • Will your recovery time exceed the waiting period?

How to Get Short-Term Disability For Surgery

How do you get short-term disability insurance to cover your surgery recovery? You must have coverage in force before the procedure in order to apply for benefits afterward. Be careful with the terms you use.

  • Getting can mean buy a policy
  • Getting can mean apply for benefits

This is how the coverage works. Make sure that you buy a private policy at least one year before the need arises. Do not assume that your state offers a public option covering temporary work absences.

Before Surgery

The number one rule is that you must get short-term disability before you know that you will need to have surgery – unless you have coverage through your state. Private and public plans work differently in this regard.

  • Private plans exclude pre-existing conditions for at least one year after the policy effective date. This means that you must purchase coverage one year before your elective (scheduled) operation.
  • State-based public programs will cover pre-existing needs for scheduled operations. However, only five states make the benefits available.
    • California
    • Hawaii
    • New Jersey
    • New York
    • Rhode Island
    • Washington State (Beginning 2020)

After Surgery

You can get short-term disability benefits after surgery if you indeed have a policy already in force and the pre-existing condition rules do not apply to your situation. Complete a claim form and return it to your insurance company for approval.

This is how the claims approval process works. The claims adjuster will compare your recovery time to the elimination period, and determine if the procedure fits the definition of a covered medical condition.

Start Time

Short-term disability benefits start for surgery after you meet the elimination period. The elimination or waiting period defines how long you must be out of work before the policy begins paying claims.

Pull out a copy of your policy or look up the information online. Your coverage may have one of these common elimination period choices: (7, 14, 30, 60, or 90 days). Then compare this to the expected recovery time for your procedure.

Your plan could make claim payments during the time your recovery extends past the elimination period. For example, an 8-week healing time minus a 2-week elimination period equals a 6-week benefit.

Recovery TimeProcedure
1 – 6 MonthsACL
6 – 8 WeeksBunion Surgery
1 – 3 MonthsCarpal Tunnel
1 – 6 WeeksGallbladder
6 WeeksHysterectomy
1 – 3 MonthsSpinal Fusion
3 MonthsTotal Knee Replacement
1 WeekWisdom Teeth Removal

Qualifying Conditions

Short-term disability may make claim payments after your surgery if it is a qualifying medical condition. The policies do not cover all operative procedures. The need must arise from an illness or accidental injury not excluded by the plan.

The plans are more likely to cover medically necessary reasons. The coverage works differently for emergency, elective, and cosmetic reasons in this regard.

Emergency

Short-term disability is most likely to cover emergency surgery recovery. The reason is simple. Emergency procedures by definition are more likely to be medically necessary. Your policy should cover emergency operations not caused by a pre-existing condition or excluded for another reason (intentional injury, playing professional sports, etc.).

Urgent operations such as colectomy, small-bowel resection, cholecystectomy (gall bladder), removal of abdominal adhesions, appendectomy, laparotomy, and open broken bone reductions fit into this category.

Elective

Short-term disability will sometimes cover elective surgery when medically necessary. Elective operations are planned, non-emergency procedures, scheduled at an appropriate time for both the surgeon and the patient. It could be required or optional.

Elective operations such as angioplasty, stent insertion, carpal tunnel, cataract removal, C-section, hip and knee replacements, hysterectomy, weight loss (bariatric, gastric bypass and lap band) fit into this category.

Cosmetic & Plastic

Short-term disability works with cosmetic and plastic surgeries differently. Consumers often think the terms mean the same thing. However, the medical community has distinct definitions that affect how your policy will handle claims while in recovery.

  • Cosmetic surgery enhances appearance by improving aesthetic appeal, symmetry, and proportion. It is not medically necessary. Your policy will not pay claims. Procedures such as facelifts, liposuction, rhinoplasty (nose job), labiaplasty (vaginal rejuvenation), abdominoplasty (tummy tuck), and fat transfers fit into this category.
  • Plastic surgery corrects dysfunctional areas of the body and is often medically necessary. Your policy may pay claims. Procedures such as cleft lip and palate repair, breast reconstruction, skin removal, and skin grafts can fit into this category.

Income When Out of Work Due to Surgery

Short-term disability insurance can provide partial income replacement while you are out of work due to surgery. However, many people do not have coverage through the state. Or, they did not buy a private policy before the need arose.

You may be wondering what alternatives exist if this describes your situation. Unfortunately, very few good options exist. Taking out a personal loan or enrolling in a debt settlement program are the remaining alternatives.

Collecting Unemployment

Most people will be unable to collect unemployment while they are out of work due to surgery. During your recovery, you do not meet any of the three universal eligibility criteria for unemployment compensation. Plus, you still could have a job.

  1. Physically able to work
  2. Available for duty
  3. Actively seeking new employment

Unemployment benefits become an option after you recover from surgery because you now meet the first criteria – you are now physically able to work. You may now be eligible if you are still out of work depending on the reason and state.

Requesting Time Off

The Family Medical Leave Act (FMLA) provides legal job protections that help when requesting time off from work for surgery. Covered employers must grant eligible employees twelve weeks of unpaid job-protected leave for an employee’s own serious medical condition.

Surgery qualifies as a serious medical condition. You can take advantage of short-term disability and FMLA at the same time – if you qualify for both. However, this is rare.

  • About 58% of employees qualify for FMLA
  • Only 22% of people have temporary disability benefits
  • A tiny 13% would then have both
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