Short-term disability qualifying conditions are too numerous to list. Categories of excluded medical conditions can help narrow down qualifying claims reasons, and provide a finite list.
Certain life and health events trigger eligible opportunities to make policy changes and adjustments such as making a purchase, or cancelling your policy. The elimination, benefit, and pre-existing condition periods define claims requirements.
- Qualifying medical conditions
- Eligible events for policy changes
- Three period definitions and carrier requirements
Short-Term Disability Qualifying Medical Conditions
Short-term disability qualifying medical conditions must prevent you from performing the primary duties of your full time occupation. Your doctor must certify the medical reason why you are unable to work.
Your policy may contain language spelling out coverage for illnesses, accidents, and mental illnesses.
Many carriers define a short-term disability qualifying illness as a sickness, infection, or disease or other abnormal medical condition, which is diagnosed after the policy effective date, causes a loss of income while the policy is in force, and is not specifically excluded by the policy.
- Recovery from normal labor and delivery is a qualifying illness for policies purchased at the worksite.
- Individual policies sold directly cover only complications of pregnancy.
- Illnesses caused by an addiction to alcohol or drugs do not qualify.
Illnesses caused by an addiction to a drug prescribed by your doctor may meet qualification guidelines. The policyholder may have to show that the drugs were taken as prescribed and not abused. Many prescription drugs have noted side effects that may cause a loss.
Your policy may exclude a number of accidental injuries as a qualifying medical condition. Each policy is different, so read the exclusion language carefully.
Below is a sample list of possible accidental injury exclusions.
- Piloting or as a passenger in a private aircraft without a published schedule
- While committing a felony
- While working at an illegal job
- Riding or driving in a motor vehicle race or stunt show
- Practicing for or playing in any professional sport
- Trying to commit suicide or any intentional injury
- Being exposed to an act of war
- Serving in the armed forces
Workers compensation covers on-the-job accidental injuries. Most injuries that occur while working are not eligible for short-term disability.
Some policies do contain a rider option to cover on-the-job accidents at a reduced benefit.
Request an online quote to determine whether to include on-the-job accident coverage.
Losses caused by mental illnesses are typically not considered a qualifying condition. You may not qualify for benefits if you have been unable to work because of any mental or emotional disorder, psychosis, or neurosis.
Many people with mental illnesses are prescribed strong drugs with negative side effects. Losses caused by these drugs may be a qualifying condition, per the above. Check your policy language carefully.
Short-Term Disability Eligible events
Short-term disability eligible events determine when you can purchase coverage, make changes to your policy features, or cancel your policy.
The three most common eligible events are open enrollment, changes in income, and changes in hours worked.
Carrier and IRS rules may restrict the timeframes when employees can purchase or drop coverage to open enrollment only. Each carrier has different open enrollment eligibility event rules.
IRS open enrollment rules apply to policies paid using pretax payroll elections. Policies paid using after-tax dollars can change elections at any time.
Change in Income
A change in income is an eligible event for adjusting your policy’s monthly amount.
It is normal for annual income to fluctuate over time. At time of application, the policyholder purchases a monthly amount pegged at a maximum of 2/3 gross monthly income.
If your annual income increases, you may now be under insured. If it decreases, you may now be over insured.
Change in Hours Worked
A change in hours worked make convert a fulltime employee into a part-time employee. Most policies cover full-time employees only.
Every policy defines eligibility criteria based on the number of hours worked per week. Change from full-time to part-time status is an eligible event to drop coverage. The carrier may not pay claims for losses incurred by part-time workers.
Short-Term Disability Qualifying Periods
Short-term disability qualifying periods determine how quickly claims payments begin, how long they may last, and if the carrier is even required to pay a claim.
The elimination period defines how quickly claims payments begin, the benefit period how long they last. The preexisting condition period knocks out many applicants who assume they have a state plan where they live.
The elimination or waiting period defines how quickly claims payments begin after a loss occurs. Most policyholders choose the elimination period when first applying for coverage.
Elimination periods can be a short as zero days for accidents, and seven days for sicknesses.
The benefit period defines how long claims payments may last for policyholders who are continuously unable to work. Policyholders choose the benefit period at time of policy application.
Benefit periods can be as short as three months, as long as twenty-four months or anywhere in between.
Preexisting Condition Period
Preexisting conditions are the most frequent reason behind why carriers deny claims.
Many carriers define a preexisting condition as an illness or medical condition for which you received medical advice, treatment, or took prescription medications twelve months prior to the policy effective date.
Many policies contain either a six or a twelve-month preexisting condition exclusion period. The carrier is not required to pay claims for any loss that occurs during the first twelve months of the policy effective date that results from a preexisting condition.
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