What health conditions automatically qualify for short-term disability?
A list of eligible medical reasons (illnesses or injuries) will never provide an accurate answer.
Your coverage disclosure statement or policy is the place to turn. The insurance company adjuster will reference this legal document when evaluating your claim for benefits.
Learn about the universal requirements and then specific rules related to your illness or injury. Complete the claim form right the first time to expedite your benefit.
Short-Term Disability Eligibility Requirements
You must first meet four broad short-term disability insurance requirements in order to be eligible for benefits. Every private policy or public program contains unique legal language and definitions. Read the terms carefully to find the exact wording.
Disclaimer: only claims personnel at your insurance carrier can make benefits eligibility determinations. This article is for informational purposes only.
Coverage in Force
Having short-term disability coverage in force is the most important eligibility requirement. Many people make the mistake of assuming that their state or employer provides this benefit automatically. This is rarely the case.
- 5 states have mandatory programs
- New Jersey
- New York
- Rhode Island
- 45 states have nothing
- Social Security does not cover temporary impairments
- Many employers do not offer the benefit
Not having a pre-existing condition is the second important short-term disability requirement. Many policies contain either a six or a twelve-month pre-existing condition exclusion period.
“A preexisting condition is an illness or medical condition for which you received medical advice, treatment, or took prescription medications twelve months prior to the coverage effective date.”
You are not eligible for benefits until you meet the exclusion limitation for pre-existing health conditions defined in your contract.
Time Off Work
How long do you have to be out of work to get short-term disability? The elimination or waiting period rule defined in your policy contract or state benefit portal answers this eligibility question.
Elimination period means the length of time during which no benefits are payable. You must be out of work longer than this contractual timeframe. Your coverage may have one of these common combinations.
|0 days||7 days|
|7 days||7 days|
|30 days||30 days|
|60 days||60 days|
|90 days||90 days|
Satisfying the short-term disability definition is the final eligibility requirement. You must meet the policy definition for being totally disabled in order to file a claim. The legal language may read as follows.
- Unable to perform all the material and substantial duties of your regular occupation
- Not engaged in any other employment or occupation for wage or profit
- Under the regular and appropriate care of a doctor
Short-Term Disability Medical Reasons
Qualifying short-term disability medical reasons are accidents or illnesses that satisfy the universal eligibility requirements outlined above. Having a health condition alone is not sufficient when filing a claim.
You must have coverage in force, not have a pre-existing condition, have been out of work long enough, and meet the disability definition.
How do you ask your doctor to help file a claim for short-term disability? Download the claim form from your insurance company or state agency. Fill out the paperwork with your personal identifying information. Then take the form to your physician and ask him or her to answer the following sample questions about your disorder.
- Is condition due to an accidental injury?
- What primary diagnosis prevents the patient from working?
- When did symptoms first appear?
- Current treatment plan
- List diagnostic tests performed
- List any surgeries performed
- How soon do you expect significant improvement in the patient’s medical condition?
- Does the patient have permanent restrictions? (Cannot do)
- Does the patient have permanent limitations? (Should not do)
- Did this condition require house confinement?
- Check activities of daily living that the patient is unable to perform
This list of possible short-term disability qualifying illnesses offers modest guidance. Look to your coverage disclosure statement for a precise definition of a covered sickness. It may be similar to this rule.
“A covered sickness is an infection, disease or other abnormal medical condition, which is diagnosed after the coverage effective date, causes a loss of income while the policy is in force, and is not specifically excluded.”
Many short-term disability policies will exclude these illnesses from coverage any deny any claims associated with these issues.
- Addiction to alcohol or drugs
- Mental illness (psychoneurosis, psychopathy, psychosis)
- Pregnancy when conception occurs before the effective date
In addition, the insurance company is likely to deny claims based on symptoms, treatments, or vague ailments alone. You need to list a specific primary diagnosis that prevents you from working rather than any of these issues.
|Back pain||Chemotherapy||Dental work|
|Exhaustion||High blood pressure||Hospitalization|
Short-term disability may cover intermittent leave without imposing a new elimination period after you first meet the totally disabled definition (see above).
Many chronic or long-term sicknesses will ebb and flow over time triggering a partial (work part-time) or recurrent (stop working then return then stop again) disability. These primary diagnoses often fit into this category.
|Cancer||C Diff Colitis||Epilepsy|
|Hypothyroidism||Irritable Bowel Syndrome||Kidney Stones|
|Lupus||Lymes Disease||Migraine Headaches|
|Rheumatoid Arthritis||Sinus Infections||Tendonitis|
|Type 2 Diabetes||Ulcerative Colitis||Uterine Fibroids|
The list of possible short-term disability qualifying accidental injuries also offers modest guidance. Instead, look to your coverage disclosure statement for a definition of covered accident. It may read similar to this statement.
“A covered accident occurs after the effective date while the policy is in force, causes a loss of income, and is not listed or excluded by name in the contract.”
Many short-term disability policies will exclude accidental injuries resulting from certain activities.
- Non-scheduled aviation
- Attempting to commit a felony
- Working at an illegal job
- Riding or driving in a motor vehicle race or stunt
- Participating in a sport for compensation
- Injuring yourself intentionally (suicide attempts)
- An act of war; serving in armed forces
Most short-term disability policies will accidental injuries that meet the definitions listed above. As before, do not list vague descriptions such as car accidents on the claim form. Rather, have your doctor provide a specific diagnosis.
|Foot/Ankle Bone||Anterior Cruciate Ligament|
|Hand/Wrist Bone||Rotator Cuff|
Workers Compensation typically addresses work-related incidents unless included as a rider.
Short-term disability covers surgery (elective and emergency) subject to all of the limitations already addressed above. Medical necessity is yet another guideline that comes into play with operations.
Medically necessary means “health-care services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.”
Cosmetic surgical procedures do not meet this standard because they address appearance: shape, size, contours, etc.