FAQ Page

   
FAQ Type:  
 

 
    
1. What do I have to do during my disability?
2. How does the Short Term Disability claim process work?
3. How does Sedgwick get the physician's information for my STD claim?
4. What should I do if my doctor determines that I will not be able to return to work on the date provided on the first certification provided by the doctor's office?
5. Can Sedgwick contact my doctor to get the necessary information to process my claim?
6. How long will it take to process my extension on my Short Term Disability Claim?
7. What happens if Sedgwick cannot get information from my doctor?
8. Why didn't Sedgwick approve my claim to the date my doctor requested?
9. Why would Sedgwick need to request a copy of my medical records?
10. How do I see the status of my claim?
11. How long will it take to process my STD claim?
12. How much can I expect to receive for my Short Term Disability benefits?
13. When will I actually receive my STD payments?
14. Why could my STD payment be late?
15. Why haven't I been paid from the first date of disability?
16. When will my STD benefits end?
17. Will deductions be taken from my STD payment?
18. I'm Going From Short-Term Disability (STD) To Long-Term Disability (LTD). What Happens Now?
19. Why Do I Have To Fill Out All These Forms for my LTD claim?
20. What Kind Of Work Information Do You Need for my LTD claim and Why?
21. How Does The LTD Process Work?
22. What Are My Responsibilities During the LTD Process?
23. What Are Sedgwick's Responsibilities during the LTD process?
24. How Long Does The LTD Decision Process Take?
25. The website indicates that my claim is approved to 2014, what does that mean?
26. What is FMLA?
27. Who is eligible to take FMLA leave?
28. How much time off am I entitled to under FMLA?
29. Do I need to work the 12 months continuously or consecutively in order to be eligible for FMLA?
30. How are the 1,250 hours calculated?
31. How is it determined if the employee has met the 1,250 hours in 12-month period criteria?
32. How is the 12-month period defined?
33. Who is considered an immediate "family member" under FMLA?
34. Does an employee have to take all 12 weeks off at once?
35. Does FMLA guarantee paid time off?
36. Can sick or vacation time count against a FMLA leave?
37. Can workers' compensation leave count against a FMLA leave?
38. Can maternity leave or pregnancy disability also be counted as FMLA leave?
39. Is medical certification required?
40. What are an employer’s notification responsibilities?
41. Can doctor's visits be covered under FMLA leave?
42. Can an employer require an employee to return to work prior to the end of the 12 week entitlement?
43. Can an employer place restrictions on how the employee spends time while on FMLA leave?
44. Can an employer make inquiries about an employee's leave during the absence?
45. Are there other circumstances in an employer can deny an employee FMLA leave or job reinstatement?
46. How do I file a Short-Term Disability claim?
47. How do I know if Sedgwick received the fax I sent?
48. What should I do if my doctor releases me to return to work earlier than my original expected return to work date?
49. What About Social Security (SSDI)?
50. Kaiser is my medical provider. What do I need to do differently?
51. How do I get access to Sedgwick's Client Site?
52. Who do I contact if I'm having a problem logging in or have lost my Log-in ID or Password?
53. How do I see the status of my employee's leave?
54. How do I see recent payments and payment history on a paid leave claim?
55. What if an employee that appears on the "Claims Missing Eligibility Data" screen is not our employee?
56. How do I view reports on the web?
57. Who do I Contact for Report Requests that are not available through the Web Site?
58. How do I Input Employee Eligibility Information?
59. How do I Input an Employer Claim Note?
60. How do I Input a Termination Date?
61. How do I inform Sedgwick of an employee’s Return to Work Date?
62. What is New Jersey Paid Family Leave (PFL)?
63. How does Paid Family Leave (PFL) differ from disability benefits provided to New Jersey employees?
64. When will New Jersey Paid Family Leave (PFL) payments begin?
65. What is the New Jersey PFL benefit?
66. Who is eligible for New Jersey PFL benefits?
67. Is New Jersey PFL employee or employer paid?
68. Are payroll deductions mandatory for New Jersey PFL?
69. When do New Jersey PFL contributions begin?
70. What is the contribution rate for New Jersey PFL?
71. How many weeks can an individual collect New Jersey PFL?
72. Will there be a waiting period for New Jersey PFL?
73. Can my employer require me to use accrued, but unused vacation?
74. How do I file a leave request?
75. What documentation will be required for a bonding leave request?
76. How does the leave process work?
77. How does Sedgwick get the physician's information for my leave request?
78. Can Sedgwick contact the physician to get the necessary information to process my leave request?
79. What happens if Sedgwick cannot get information from the physician?
80. How do I know if Sedgwick received the fax I sent?
81. What should I do if I return to work earlier than my original expected return to work date?
82. Kaiser is the medical provider. What do I need to do differently?
83. How long will it take to process my extension request for my leave?
84. Why didn't Sedgwick approve my leave to the date the physician requested?
85. What do I have to do during my leave?
86. How long will it take to process my leave request?
87. How much can I expect to receive for New Jersey PFL benefits?
88. When will I actually receive my benefits?
89. When will PFL benefits end?
90. Will deductions be taken from a benefit payment?
91. May an employer require employees to take all 6 weeks of PFL at once?
92. Does New Jersey PFL offer job protection?
93. How is the New Jersey PFL benefit affected if the employee receives sick leave benefits and PFL at the same time?
94. Are New Jersey Paid Family Leave (PFL) benefits taxable?
95. How does Sedgwick obtain my tax status?
96. What if my employer pays my PFL benefits rather than Sedgwick?
97. Why could my benefit payment be late?
98. Why haven't I been paid from the first date of my leave request?
99. What is self-insurance or self-funding?
100. What is a Third Party Administrator (TPA)?
101. What are the requirements to establish a private plan in Puerto Rico?
102. What is the Puerto Rico TDI background?
103. What is the Puerto Rico TDI benefit formula?
104. What are the Puerto Rico TDI plan costs?
105. What services does Sedgwick provide employers and their employees?
106. Are alternative plans permitted in Rhode Island?
107. What is Rhode Island's State Plan Background?
108. What is the Rhode Island TDI benefit formula?
109. What are the Rhode Island TDI plan costs?
110. How do we start a Hawaii private plan?
111. What are the advantages to self-insuring Hawaii TDI?
112. What are the alternative plan options in Hawaii?
113. What are the Hawaii plan costs?
114. What are the requirements to establish a private plan in Hawaii?
115. What is the Hawaii benefit plan formula?
116. What's needed for Hawaii TDI program participation?
117. What are New York's DBL plan benefits?
118. What are New York's DBL plan costs?
119. What are the requirements to establish a New York DBL private plan?
120. What is New York's insured plan option?
121. What is the New York Disability benefits law background?
122. What are the New Jersey plan costs?
123. What are the requirements to establish a private plan in New Jersey?
124. What are the results of participation in the New Jersey state plan?
125. What is the New Jersey benefit formula?
126. What are the California plan costs?
127. What are the results of participating in the California state plan?
128. What is the California benefit formula?
129. How many states provide statutory disability programs?
130. Why self-insure state disability?
131. What are the end results of Sedgwick's Health & disability model?
132. What are the key features of Sedgwick's FML Service offering?
133. What do our clients have in common?
134. What is FMLA?
135. What is Sedgwick's FML Service?
136. How does outsourcing work?
137. What are the advantages of a self-insured plan with Sedgwick as your administrator?
138. What are the advantages of using Sedgwick's integrated disability model?
139. What are the advantages to pre-tax deductions for mandated state disability programs?
140. What are the differences between a self-funded and an insured disability plan?
141. What are the hidden costs of disability?
142. What are the sources of disability benefit coverage?
143. What is integrated disability management?
144. What is self-insurance or self-funding?
145. What is the importance of managing disability?
146. What should you expect from your plan administrator or TPA?
147. Who does Sedgwick serve?
148. Why health and disability?
149. Why is self-funding short-term disability important to large employers?
150. Why is sick leave one of the most difficult absences to manage?
151. Why self-fund a disability plan?
152. Why self-fund long-term disability?
153. Why should salary continuation be handled by a third party administrator?
154. What is California Paid Family Leave (PFL)?
155. How does California Paid Family Leave (PFL) differ from disability benefits provided to California employees?
156. When will California Paid Family Leave (PFL) payments begin?
157. What is the California PFL benefit?
158. Who is eligible for California Paid FamilyLeave?
159. Is California PFL employee or employer paid?
160. Are California PFL payroll deductions mandatory?
161. When do California PFL contributions begin?
162. What is the contribution rate for California PFL?
163. How many weeks can an individual collect California PFL?
164. Will there be a waiting period for California PFL?
165. Can my employer require me to use accrued, but unused vacation?
166. How do I file a leave request?
167. What documentation will be required for a bonding leave request?
168. How does the leave process work?
169. How does Sedgwick get the physician's information for my leave request?
170. Can Sedgwick contact the physician to get the necessary information to process my leave request?
171. What happens if Sedgwick cannot get information from the physician?
172. How do I know if Sedgwick received the fax I sent?
173. What should I do if the physician releases me to return to work earlier than my original expected return to work date?
174. Kaiser is the medical provider. What do I need to do differently?
175. What should I do if the physician determines that I will not be able to return to work on the date provided on the first certification provided by the physician?
176. How long will it take to process my extension request for my leave?
177. Why didn't Sedgwick approve my leave to the date the physician requested?
178. What do I have to do during my leave?
179. Why would Sedgwick need to request a copy of the medical records?
180. How long will it take to process my California Paid Family Leave (PFL) request?
181. How much can I expect to receive for California PFL benefits?
182. When will I actually receive my PFL benefits?
183. When will California PFL benefits end?
184. Will deductions be taken from a benefit payment?
185. May an employer require employees to take all 6 weeks of California PFL at once?
186. Does California PFL offer job protection?
187. If an employer does not require their employees to use vacation, can the employee still use their vacation?
188. How are California PFL benefits affected if the employee receives sick leave benefits and PFL at the same time?
189. Are California Paid Family Leave (PFL) benefits taxable?
190. How does Sedgwick obtain my tax status?
191. What if my employer pays my PFL benefits rather than Sedgwick?
192. Why could my benefit payment be late?
193. Why haven't I been paid from the first date of my leave request?


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Question : What do I have to do during my disability?
 
Answer :
You have a very important role in the STD process. To ensure you receive all of the STD benefits to which you are entitled, you must:
  • Sign and return all forms to Sedgwick as soon as possible
  • See your doctor on a regular basis and follow the treatment plan
  • Stay in touch with Sedgwick and your Supervisor; provide information as requested
  • Return to work when your disability ends
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Question : How does the Short Term Disability claim process work?
 
Answer :

You should first file your claim with Sedgwick. How Do do I file my claim?

Once you have filed your claim, Sedgwick will contact your employer and obtain the employment information (your date of hire, salary, employee status, etc.) that we'll need to begin processing your claim.

Your claim will be assigned to a Disability Representative for review. If you have a short-term disability claim, a determination resulting in an approval, denial, or request for additional information will be made within 4 business days. If your claim is approved, you will receive your payment from either Sedgwick or your employer, depending on the payment schedule your employer has established with Sedgwick. If your claim is denied, you will be notified in writing. If Sedgwick needs additional information, you will be contacted by telephone or letter (depending on the information needed.

If you have not recovered or you are not able to return to work on your scheduled return to work date, your doctor may call Sedgwick to report the extension, or you can download the Supplemental Certification Form for Extension of Disability form for your doctor to complete. If you download this form, fill out the top portion and have your physician complete the bottom section of the form, and either fax or mail to Sedgwick. Once Sedgwick has received your extension, we will review the extension and a determination resulting in an approval, denial, or request for additional information will be made within 4 business days.

If you miss a payment and your claim is subsequently approved or extended, your current Short Term Disability benefit amount will be combined with any benefits you were due from the prior period, and paid to you in your next payment. Sedgwick makes every effort to approve and pay claims in a timely manner to avoid any disruption to the claimant. However, there are times when we are unable to approve and pay a claim on the scheduled payment period as determined by your employer. This could be caused by a delay in filing the claim, receipt of medical documentation or other required information. If this should happen any amount owed will be paid on the next scheduled payment date.

If you have any questions, you can contact us at the following numbers: Sedgwick Contacts

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Question : How does Sedgwick get the physician's information for my STD claim?
 
Answer :
If you are filing a new claim and we have not received information from your physician for this claim, tell your doctor to call Sedgwick immediately. Your physician will need to supply Sedgwick with medical information regarding your disability. If your physician is unable to call, you can download the Certification Form for Initial Certification of Disability for your physician to fill out. Fill out the top portion of the form and instruct your physician to fill in the bottom portion of this form and fax it to Sedgwick as soon as possible, to complete the filing process of the medical portion of your claim.

If you have not recovered or you are not able to return to work on your scheduled return to work date, download the Supplemental Certification Form for Extension of Disability Benefits and fill out the top portion. Have your physician complete the form and either fax or mail it to Sedgwick in order to continue your disability benefit payments.

PLEASE NOTE: Filing does not guarantee you will receive benefits. You must first meet the medical criteria and provisions of your company's plan. For a copy of the plan document, please contact your benefits department.

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Question : What should I do if my doctor determines that I will not be able to return to work on the date provided on the first certification provided by the doctor's office?
 
Answer :
Please do the following if your doctor determines you are unable to return to work on the date they provided on the original certification: Ask your doctor's office if they will call Sedgwick as soon as possible, to report the new return to work date and provide verification of your diagnosis or have your doctor complete the Request for Extension of Self-Insured Disability Benefits (PDF) form. This extension form must be completed in its entirety and signed by your doctor's office and may be faxed to Sedgwick. After your doctor's office has provided Sedgwick with this information, Sedgwick will review the extension and advise you if the additional time is approved. (After Sedgwick receives the completed extension, our goal is to make a determination or request additional information within 4 business days.)

Please Note: Your doctor may be extending your disability but may not have an exact Return to Work Date available at this time. Sedgwick requires a specific date to process the extension. The doctor's office may use the date of your next appointment if they are unsure of your return to work date. If you are unable to return to work at that time, they would need to provide us with another extension. Multiple extensions can be requested. Sedgwick cannot process incomplete extensions.

To avoid a delay in payment of your benefits we suggest you request an extension as soon as you are aware one will be needed.
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Question : Can Sedgwick contact my doctor to get the necessary information to process my claim?
 
Answer :

If you are experiencing difficulty having your physician provide disability information to Sedgwick, please contact us with your physician's fax number and we can fax a form to your physician's office in an attempt to obtain the required objective medical information.

If your employer has established procedures with Sedgwick to call your physician upon initial filing, we will phone your physician for you.

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Question : How long will it take to process my extension on my Short Term Disability Claim?
 
Answer :
It is Sedgwick's goal to process an extension of a short-term disability claim within 4 business days from the time the completed extension is received. You can check the status of your existing claim by accessing the Check Claim Status page. Occasionally there is a need for additional medical records. If additional medical records are required to make a decision regarding your request for extension, your doctor's office will be contacted within 4 business days.
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Question : What happens if Sedgwick cannot get information from my doctor?
 
Answer :
If you have requested assistance in obtaining medical information from your physician, Sedgwick will assist you. However, if we are unable to obtain the necessary medical information from your physician, it is ultimately your responsibility. If Sedgwick does not receive objective medical information to support your disability, your STD claim cannot be approved.
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Question : Why didn't Sedgwick approve my claim to the date my doctor requested?
 
Answer :
Sedgwick reviews the information provided by your doctor and determines if there is medical evidence to support your inability to perform your job duties. If your doctor has indicated you will be disabled beyond normal guidelines for your condition, Sedgwick will approve your claim to a certain date, and re-review your claim when that date arrives (to see if the additional time is supported).
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Question : Why would Sedgwick need to request a copy of my medical records?
 
Answer :
If the information presented by your doctor does not completely support your disability, Sedgwick may request a copy of your medical records in an attempt to obtain objective medical information.
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Question : How do I see the status of my claim?
 
Answer :
Click here to see the status of your claim.
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Question : How long will it take to process my STD claim?
 
Answer :
It is Sedgwick's goal to process a short-term disability claim within 4 business days from the date all required information is received. You can help speed up the process by doing the following:
  • Sign and return to Sedgwick all forms as quickly as possible
  • Ensure your doctor immediately provides Sedgwick with the medical information requested
  • Stay in touch with Sedgwick throughout your disability leave

PLEASE NOTE: You can also check the status of your existing claim by accessing the Check Claim Status page.

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Question : How much can I expect to receive for my Short Term Disability benefits?
 
Answer :
The actual amount of your Short Term Disability payment is determined by several factors:
  • The percentage of replacement income your plan specifies (this may be less than 100% of your usual wages; may be based on length of service, or other requirements in the plan)
  • Income received from other sources could be deducted from your gross benefit amount
  • Your employer may have made arrangements for Sedgwick to pay your health insurance, 401K, etc. while you are disabled, (and would be deducted from your payment)
  • Taxes could be withheld if you are covered under a taxable plan.
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Question : When will I actually receive my STD payments?
 
Answer :
Sedgwick wants you to receive the STD benefits for which you may be eligible as quickly as possible. In fact, Sedgwick's goal is to process your claim within 4 business days from the time we receive all the necessary information. Sedgwick will make every effort to obtain the required objective medical information from your doctor. You can help speed up the process by doing the following:
  • Sign and return to Sedgwick all forms as quickly as possible.
  • Ensure your doctor immediately provides Sedgwick with the medical information requested
  • Stay in touch with Sedgwick throughout your disability leave.

If your claim is approved, you will receive your payment from either Sedgwick or your employer, depending on the payment schedule your employer has established with Sedgwick.
PLEASE NOTE: You can also check the status of your existing claim by accessing the Check Claim Status page.

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Question : Why could my STD payment be late?
 
Answer :
Below is a list of possible reasons your STD payment could be late.
  • Sedgwick has not yet received information supporting your disability
  • Information received by Sedgwick is incomplete and/or Sedgwick needs additional information on your claim.
  • The necessary information was received after the normal payroll cycle had run
  • A waiting period may apply to your disability

PLEASE NOTE: If you miss a payment and your STD claim is subsequently approved, your current STD benefit amount will be combined with any benefits you were due from the prior pay period and paid to you in your next payment.

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Question : Why haven't I been paid from the first date of disability?
 
Answer :
Some plans have a waiting period that must be satisfied before benefits are payable. In order to find out if your plan has a waiting period and what that waiting period consists of, please refer to your benefits booklet or summary plan description.
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Question : When will my STD benefits end?
 
Answer :
Your disability payments could end due to any of the following situations:
  • You are no longer considered disabled under the Plan
  • You have reached the maximum benefit amount or time allowed under the Plan (see your Benefits Booklet or Summary Plan Description to find out the applicable provision)
  • You return to work

PLEASE NOTE: Your actual benefit plan could contain additional reasons for your benefits to end. You should consult your Benefits Booklet or Summary Plan Description for more information.

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Question : Will deductions be taken from my STD payment?
 
Answer :
Depending on the plan under which you are covered, some of the deductions that could be taken from each of your STD payments include:
  • Taxes
  • Health Insurance
  • Other Income/Benefits
  • 401K
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Question : I'm Going From Short-Term Disability (STD) To Long-Term Disability (LTD). What Happens Now?
 
Answer :
When an STD claim appears it will exceed the maximum period allowed on a STD claim, the STD claim will be 'flagged' for review and referred to the LTD examiner. When additional information is needed in processing an LTD claim, Sedgwick will send specific forms to be completed.

If Sedgwick is not handling your STD claim, but is administering your employer's LTD plan, contact your employer for instructions on filing your LTD claim.
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Question : Why Do I Have To Fill Out All These Forms for my LTD claim?
 
Answer :
When determining if an employee is disabled, the examiner must request information related to job duties, the claimant's functional capacity and more. Some of the typical forms or requests during the LTD process are as follows:

Daily Activities Questionnaire (DAQ): This form may be sent to the claimant at various times during the LTD process. This form asks a multitude of questions regarding the claimant's daily activities. The DAQ elicits such things as the claimant's diet, daily activities, and physical demands, so we may better assess the claimant's capabilities and life style related to their disability.

Job History Questionnaire: A Job History Questionnaire may be sent at various times during the LTD process, when the examiner needs to determine if a claimant has the ability to function in another occupation.

Physical Capacity Evaluation (PCE): This is an assessment of the impact of the impairment on the claimant's physical capacity to do work related activities. It considers any related limitations from symptoms.

Mental Residual Functional Capacity Assessments (MRFCA): This form helps in assessing the impact of the claimant's mental capacity to do work. It considers any related limitations from symptoms. There are four criteria concerning the basic mental demands of an occupation: Understanding, carrying out, and remembering simple instructions, use of judgment, responding appropriately to usual work situations (co-workers, supervisors etc.), and dealing with changes in a routine work setting.

Attending Physician Statement (APS): This form is similar to the Physician Certificate (PC) that is required for STD claims. This form requests medical information necessary to review and adjudicate a claim.
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Question : What Kind Of Work Information Do You Need for my LTD claim and Why?
 
Answer :
The employer provides a statement about the claimant's occupation, and a job or position description, which contains detailed information about the employee's job. The job or position description is a critical factor in disability evaluation. The job description is used to determine the physical components of a particular job, and whether that position is sedentary, light, medium, or heavy work. The job description is significant in evaluating disability duration and severity and, in some circumstances, determining whether modified duty options should be explored (e.g., some conditions which would result in disability for an individual performing heavy work will have little or no impact on an individual performing a sedentary job).
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Question : How Does The LTD Process Work?
 
Answer :
When the first portion of the LTD application is received, a claim file must be established. In order to be eligible, your employer's LTD plan must be in effect and you must be covered under the terms of the plan on the date you became disabled.

A complete review and evaluation of all medical evidence must be done in order to make a disability determination. Disability may only be established on the basis of objective medical evidence, including clinical findings. Physicians do not determine disability. Medical sources provide evidence; the claim professional determines disability.

In order to determine whether a claimant is disabled from performing his/her occupation, the examiner must determine the functional requirements of the claimant's occupation. To make this determination, the examiner must request various employment related documents.

Each portion of the LTD application must be reviewed and missing information may be requested. Any inconsistencies, omissions, and errors must be documented and resolved before Sedgwick can approve a claim.
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Question : What Are My Responsibilities During the LTD Process?
 
Answer :
The claimant plays an important role in the LTD process. It is the responsibility of the claimant to bring to Sedgwick's attention, everything that supports their disability. They may do so by furnishing medical and other evidence that allows Sedgwick to reach a conclusion about the disability and the effects on inability to work. They should provide comprehensive information about:
  • The treating physicians,
  • The recommended treatment,
  • Their job responsibilities,
  • Their educational level and past work experience, and
  • Other sources of income applicable to the LTD plan.
Claimants further assist in the process by actively participating in the gathering of information, completing authorizations and other required forms, following the recommended treatment plan, attending all assessments, and returning to work as soon as possible.
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Question : What Are Sedgwick's Responsibilities during the LTD process?
 
Answer :
It is Sedgwick's responsibility to gather supporting information necessary for accurate case decisions, to communicate clearly with the claimant, and to provide timely assessments. It is also our responsibility to identify early intervention candidates, and to return the claimant to work whenever possible.
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Question : How Long Does The LTD Decision Process Take?
 
Answer :
This depends on several factors, including the amount of additional information Sedgwick may need to make an accurate decision. Once Sedgwick has all the information required to thoroughly assess the claim, the claim determination will be reached as timely as possible.
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Question : The website indicates that my claim is approved to 2014, what does that mean?
 
Answer :
You are approved until 2014 and will stay approved provided that you remain disabled and continue to meet your Plan's provisions.
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Question : What is FMLA?
 
Answer :
The Family Medical Leave Act is a federal law enacted in 1993 which requires employers with more than 50 employees to provide eligible workers up to 12 weeks of unpaid leave for birth, adoptions, foster care placement, and illness of employees and/or members of their families. Many states have also passed leave laws that must be addressed in conjunction with the Federal FMLA.
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Question : Who is eligible to take FMLA leave?
 
Answer :
An individual is eligible for FMLA if they have met the following criteria:
  1. Have at least 12 months of service for their employer and
  2. Worked for at least 1,250 hours in the 12 months prior to the date the leave commences and and
  3. Work at a location where at least 50 employees are employed by the employer within 75 miles.
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Question : How much time off am I entitled to under FMLA?
 
Answer :
Eligible employees are entitled to 12 work weeks during a 12-month period.
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Question : Do I need to work the 12 months continuously or consecutively in order to be eligible for FMLA?
 
Answer :
No. All time worked for the employer is counted; the 12 months do not have to be continuous or consecutive.
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Question : How are the 1,250 hours calculated?
 
Answer :
Sedgwick calculates the hours an employee actually worked for the employer. Paid and unpaid leave are not included in the calculation.
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Question : How is it determined if the employee has met the 1,250 hours in 12-month period criteria?
 
Answer :
Sedgwick will examine the employee's record of hours worked in the past 12 months prior to the start of the leave. The employee will probably meet the hours worked requirement for FMLA benefits if he/she has worked 40 hours per week in the past 7 months prior to the start of his/her leave.
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Question : How is the 12-month period defined?
 
Answer :
Employers may choose one of the four options available to calculate the 12-month period:
  1. Calendar year (January 1st to December 31st)
  2. Fixed 12 month calendar year (such as a fiscal year, the employee's anniversary date with the employer, or a year required by state law)
  3. A 12- month period rolling forward from the date an employee uses FMLA Leave
  4. A 12-month period rolling backward from the date an employee uses FMLA Leave
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Question : Who is considered an immediate "family member" under FMLA?
 
Answer :
FMLA defines an immediate family as employee's parent, spouse, and minor child. In-laws are not included in the definition of an immediate family member. You may also be eligible to take care of a child 18 years and older if he/she is "incapable of self-care" because of mental or physical disability.
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Question : Does an employee have to take all 12 weeks off at once?
 
Answer :
No. An employee may be eligible to take FMLA intermittently or in blocks of time over the 12-month period.
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Question : Does FMLA guarantee paid time off?
 
Answer :
No. If an employee is eligible for FMLA, the law only requires that the employer allow the employee to take time off. However, an employee may elect and/or the employer may require an employee to use any accrued paid time off.
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Question : Can sick or vacation time count against a FMLA leave?
 
Answer :
Yes, paid leave may be counted against the 12-week FMLA leave entitlement if the employee is properly notified of the designation when the leave begins.
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Question : Can workers' compensation leave count against a FMLA leave?
 
Answer :
Yes.
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Question : Can maternity leave or pregnancy disability also be counted as FMLA leave?
 
Answer :
Yes.
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Question : Is medical certification required?
 
Answer :
Yes. In order to be eligible for FMLA benefits, Sedgwick requires a signed medical certification stating that the employee (or employee's family member requiring his/her assistance) has a serious health condition.
Department of Labor E-Laws Advisor: http://www.dol.gov/elaws/
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Question : What are an employer’s notification responsibilities?
 
Answer :

Some of the employer’s responsibilities include, but are not limited to:

  1. The FMLA poster must be in a language the employees can read, and posted on the employer’s premises, in a "conspicuous place" where employees are employed.
  2. An employer's handbook must discuss an employee's FMLA rights and obligations as well as the employer's policies regarding FMLA, leave, wages, attendance, and other related matters.
  3. Advise employees of FMLA eligibility within five business days of employee's notice of the need for FMLA leave. Such notice should be submitted to the employee, in writing, and detail the employer's expectations and the obligations of the employee regarding the FMLA leave.
  4. Provide notice to employees when you change the method of measuring the 12-month period.
  5. Provide advance notice to the employee that he/she may loose plan coverage after the individual has failed to make the required group health benefit premium payments.

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Question : Can doctor's visits be covered under FMLA leave?
 
Answer :
Maybe. Continuing treatments by a health care provider are covered under FMLA. However, the employee would be required to submit certification that he/she has a serious health condition.
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Question : Can an employer require an employee to return to work prior to the end of the 12 week entitlement?
 
Answer :
An employer may deny the continuation of FMLA leave due to a serious health condition if the employee fails to provide the required medical certification. However, the employer may not require an employee to return to work early by offering an employee a light duty assignment.
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Question : Can an employer place restrictions on how the employee spends time while on FMLA leave?
 
Answer :
If an employer has established policies regarding outside employment (while on paid or unpaid leave) they may apply those policies to employees on FMLA leave. Otherwise, the employer may not restrict an employee's activities. However, the protections of FMLA will not cover situations where the reason for leave no longer exists and/or where the employee has not provided required notices or certifications, or where the employee has misrepresented the reason for leave.
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Question : Can an employer make inquiries about an employee's leave during the absence?
 
Answer :
Yes. The employer may ask the employee questions to confirm whether the leave needed or being taken qualifies for FMLA purposes, and may require periodic reports on the employee's status and intent to return to work after leave. Further, the employer has the option of sending the employee (at the employer's expense) to a second medical opinion. The employer may also have their health care provider contact the employee's health care provider, with the employee's permission, to clarify information in the medical certification or to confirm that it was provided by the health care provider.
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Question : Are there other circumstances in an employer can deny an employee FMLA leave or job reinstatement?
 
Answer :
There are a variety of reasons why an employee may not be reinstated. Some examples are:
  1. An employer may deny reinstatement, in certain circumstances, to "key" employees or to employees who would have been laid off or terminated had they continued to work during the FMLA leave period.
  2. An employer may deny reinstatement to employees who give unequivocal notice that they do not intend to return to work.
  3. An employer may deny reinstatement to employees who have exhausted their 12 weeks of FMLA leave in the designated "12 month period" and are unable to return to work.
  4. An employer may deny or delay reinstatement to employees with a serious health condition who fail to provide a medical certificate of fitness for duty to return to work.
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Question : How do I file a Short-Term Disability claim?
 
Answer :
If your employer does not require you to file your claim directly with them (very few do), then you may file with Sedgwick using the procedures described below:
To file your short-term disability claim online: Use our self-service online claim form on our website. Once your claim is entered into our system, you will receive an email with your Sedgwick claim number.

To file your claim by telephone: Call Sedgwick at the toll-free phone number listed on your benefits card. If you do not have your benefits card, you can call us on our main claims line at (818)591-2772. A customer service representative will take your claim information over the phone, and provide you with additional information. Be sure to note the Sedgwick claim number provided to you.


After you have filed your claim online or by telephone, you need to take the following 4 steps to ensure the fastest possible processing of your claim:
    1) If you have not already done so, notify your employer of your disability.

    2) Have your doctor's office call Sedgwick to certify your disability. This is very important, since we cannot process your claim until your doctor has contacted us. (Remind them that when they call us, they will need your medical file and social security number available.) Should your doctor require a "release" from you before they will contact Sedgwick, you can download the Release of Information Form. Complete it, and fax it to your physician.

    If your doctor prefers to mail or fax the certification to Sedgwick (we don't recommend this, since it may delay your claim), you may download the Certification Form for Initial Certification of Disability. Fill out and sign the top portion, then forward the entire form to your doctor's office. Once they complete the remainder of the form and send or fax it to Sedgwick, we can begin working on your claim. (If your medical provider is KAISER, click here.)

    We suggest that you follow up with your doctor's office until you are assured that Sedgwick has received the medical certification. Once we have your physician and employer information, short-term disability claim processing usually takes just 4 days.

    3) Complete and return the forms sent to you. Sedgwick will be sending you a Release of Information Form and a Right of Reimbursement Form in the mail. Please verify that the information is correct, sign and date the forms, and immediately return them to Sedgwick by fax or mail. Our general fax number is (818) 591-7664. (We need you to fill out these forms, even if you already did so in step #2)

    4) Continue to follow up on the status of your claim on a regular basis. You can check the status of your claim anytime on our website www.SedgwickCMS.com/calabasas (you'll need to register first using your Sedgwick claim #). You can also obtain claim status on our Automated Telephone Voice Response System at the toll-free number indicated on your benefits ID card or in your benefits booklet. Our customer service representatives are available between the hours of 6:00 A.M. and 4:45 P.M., Monday through Friday, Pacific Time for email and phone call inquiries.

PLEASE NOTE: Filing a claim for disability does not guarantee that you will receive benefits. You must first meet the medical criteria and provisions of your company's plan. For a copy of the plan document, please contact your benefits department.
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Question : How do I know if Sedgwick received the fax I sent?
 
Answer :
Sedgwick logs in all faxes received and they can be found in the Document Delivery screen.
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Question : What should I do if my doctor releases me to return to work earlier than my original expected return to work date?
 
Answer :
Contact Sedgwick immediately, and inform us of your early return to work date. When you report to work, present the signed release form to your Supervisor or HR representative.
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Question : What About Social Security (SSDI)?
 
Answer :
Sedgwick will assist you in making Social Security Disability assessment if you are on LTD.

The definition for Social Security disability is the inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or has lasted or can be expected to last for a continuous period of not less than 12 months.

Social Security legal requirements state that disability definition requirements must be met before the claimant reaches age 64 and 7 months. An applicant must be fully insured. Usually a fully insured claimant has 40 quarters (less are required for individuals under the age of 31) and must be currently insured. If the claimant meets insured status, the medical aspects of the claim are fully developed. Extensive correspondence with medical and vocational sources is conducted; claimants are required to assist. A consultative examination is pursued when it is necessary to obtain more detail or clarification about the claimant's condition.

If the application for SSDI benefits is approved, the claimant is issued an Award Certificate. The Award Certificate contains the entitlement date, payment amounts and effective dates, medical re-exam date, (if any), the claimant's rights and responsibilities, and indication if the SSDI benefit is reduced by any known State Disability or Worker's Compensation amount. Your LTD benefits may be reduced when Social security benefits are approved.
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Question : Kaiser is my medical provider. What do I need to do differently?
 
Answer :
Kaiser needs a signed Medical Release from you before they will provide Sedgwick with medical certification for your disability. There are three options for providing this to Kaiser:
  1. A hand-written note with your signature and date authorizing them to release information to Sedgwick
  2. The Kaiser Release of Information form given to you by Kaiser at each visit
  3. The Sedgwick Release of Information Form which you will receive from Sedgwick after filing your claim (or one can be downloaded directly from our website).
Be sure to take this important step of providing Kaiser with a release as soon as possible, as the Kaiser Disability Office will not release information without one of these forms. (Most Kaiser locations will accept a fax.)

To assist the Kaiser Disability Department in providing medical certification, you may also provide them with a Certification Form for Initial Certification of Disability (Physician's Certificate) at the time you provide them with your medical release form.
You may also ask them to phone in your certification by having them call the toll-free 800 number for Sedgwick (this method is the quickest way to expedite your claim). If they will not call Sedgwick, follow the steps listed above.

Continue to follow up with your Kaiser location until you are assured that the forms have been completed and sent to Sedgwick. You can check the status of your claim by going to our Claimant Home Page, and clicking "Check the Status of Claim". Just follow the easy instructions for registering to see all details of the status of your forms and claim information.

If you are planning a future disability (e.g. pregnancy, surgery), you can expedite your claim by downloading and printing the Physician's Certificate and Release of Information forms ahead of time and taking them to your Kaiser Disability Office.

Kaiser's website is: www.kaiserpermanente.org

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Question : How do I get access to Sedgwick's Client Site?
 
Answer :

Access to Sedgwick's Client Site is assigned by Sedgwick based on arrangements with our client's corporate offices. Due to confidentiality issues and access limitations, Sedgwick will only provide site access to certain Human Resources and Benefits Personnel. If you are interested in having access to our site, please contact your corporate Human Resources or Benefits Personnel for further information.

Once it has been determined that access will be provided, Sedgwick will contact you directly and provide you with a Log-in ID and Password to access the site.
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Question : Who do I contact if I'm having a problem logging in or have lost my Log-in ID or Password?
 
Answer :

In order to log in to Sedgwick's Client Site, you need a User ID and password and need to be approved by Sedgwick (and your Company, if necessary) to have access to the Client site. If you are having problems with, have forgotten your Log-in ID or Password or you wish to cancel your log-in or change your password at any time, please contact your Sedgwick Account Manager for assistance.
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Question : How do I see the status of my employee's leave?
 
Answer :


After logging on, click "claims" from the navigation bar. Click the claim number you would like to view; the claim will appear. The current status will appear on the screen. For a more detailed description of the status, click "View Claim Details" to view the current status and most recent payment information. Use your browser "back" button to return to the previous screens.
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Question : How do I see recent payments and payment history on a paid leave claim?
 
Answer :

After logging on, click 'Claims' from the navigation bar. Click the claim number you would like to view; the claim will appear. Click 'View Claim Details' to view current status and most recent payment information. For payment history and details, click 'View Details and Payment History'. A list of all payments will be displayed. To view details on a specific payment, click 'Payment Details' to view taxes, offsets, credits, etc. (if applicable). Use your browser 'back' button to return to the previous screens.

Please note: If Sedgwick is not producing actual benefit payments for your employees, you will see Voucher information and Voucher History, rather than payment history. If dollar amounts appear, these amounts are the 'adjusted gross' that Sedgwick has reported to the employee and taxes and other deductions will be taken out by the employer when the payment is processed.
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Question : What if an employee that appears on the "Claims Missing Eligibility Data" screen is not our employee?
 
Answer :


If you receive an email notification of a claim filed and the employee listed is not one of your employees, simply reply to the email indicating to Sedgwick that this is not one of your employees and Sedgwick will remove the employee from your list of claims (please allow up to 4 business hours for this to occur). If you notice this error while in the system, click on the Claim Data Input button on the left navigation bar and then select the claim. Under the Employer Claim Notes field enter a note to indicate that this is not one of your employee's. Click on the Update Record button. Sedgwick will receive the information and remove the employee from your list of claims (please allow up to 4 business hours for this to occur).
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Question : How do I view reports on the web?
 
Answer :


This utility provides you with the ability to performing real-time queries against your company-specific claims and payment data. Our on-line reporting system is designed to support our clients' preferences for information, by allowing you to selectively retrieve individual or groups of claims by a wide variety of criteria, including disability period, business unit, or claim status.

Please follow the simple steps below to generate your customized disability claim report:

Select the fields you would like to have on your report and select 'Continue'. (The employee name, last 4 digits of Social Security Number, and claim number will appear on all reports.)

Drill down to the desired plan and/or organizational level of claim activity detail by making your selections from each of the screens, as described below, and selecting 'Continue' after each screen:

  • Client Name: Narrow your query further by choosing the specific Client Name you want. Note: The Client Name is associated with the Client Number Sedgwick has assigned you. You may have more than one Client Number if more than one disability checking account exists or if they were assigned for procedural reasons.

  • Plan Number: Continue to refine your query by selecting plan number(s) from among all possible plans you have. Note: you may have a different plan for each of the various plan types we administer for you (i.e., ERISA STD, LTD, New York DBL, California Voluntary plan, etc.)

  • Business Unit: If Sedgwick is capturing and verifying the Division Number and/or Work Location Number on your claims, you will have the ability to refine your query one additional step by selecting a particular Division or Work Location. If Sedgwick is not capturing this information, this screen will not appear.
Once your data is displayed on the screen, you have the following options:
  • View payment and status details of a particular claim by clicking on the individual Claim # hyperlink.

  • Sort your data by Claim Number, Last Name, Disability Date, or Claim Status Code. Simply choose one of the four options on the Sort By drop down menu at the top of the screen; select 'Sort' to resort your data..

  • Search for claims on a particular employee using Claim Number, Last Name, or last four digits of the employee's SSN. Simply choose one of the options on the Search By drop down menu at the top of the screen, enter the criteria; select 'Search' to bring up your requested data..

  • Save your report settings (i.e., Client, Plan and Business Unit selection) by selecting the option Save Report Settings at the top of the report. Select an empty slot from the 5 slots on the screen (if no empty slots exist, you may overwrite an existing report setting). Enter a name for the report selection criteria and click "Save". Saved report settings will always display current data only. The saved report setting will appear on the second page of Client Reporting (after you choose the fields for your report) the next time you access a report..

  • Print your report by selecting Printer Friendly Version at the top of the report. The report will appear on your screen in a print ready format. IMPORTANT: Set your printer settings to landscape, and reduce to fit on page, for optimal printing. Should your printing results be less than optimal, use the download file option instead and load the data into a program that will allow you to print it, as you like.

  • Download your report by selecting Download This Report (.csv format) at the top of the report. You will be prompted to either 'open' the report or 'save' it. We suggest you save the report to a drive on your computer, as it will be faster to manipulate the data and create your report.

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Question : Who do I Contact for Report Requests that are not available through the Web Site?
 
Answer :


If the data provided on Sedgwick's website is not enough to provide you with the information you are looking for, and you need assistance with creating special reports, need information on state reporting requirements or need assistance using the reporting function on the website, please contact your Account Manager for assistance.

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Question : How do I Input Employee Eligibility Information?
 
Answer :


If you are providing eligibility information to Sedgwick via the web, you will receive a notification email each time an employee files a claim with Sedgwick. At that time we are requesting you to provide Sedgwick with eligibility information directly online.

To enter employer eligibility information on a waiting claim, just click Eligibility Input from the navigation bar. From there, you may view a list of all current claims that are Missing Employer Data. Click on the claim you wish to enter the eligibility information, and the input screen will appear with the claim number you selected.

Please answer all questions on the form, verify the information is correct, and click the SUBMIT button to provide the information to Sedgwick. The system will request that you review the information one last time before submitting. If the data is correct, click OK. If you wish to make a change, click Cancel, return to the screen and make any necessary changes before clicking the SUBMIT button again.

If Sedgwick has been instructed to take elective deductions from your employee’s disability check for a particular plan, once you click SUMBIT, after completing the first page of employer eligibility information, a "Sedgwick Elective Deduction Entry" screen will automatically pop up. After confirming that you want elective deductions taken from this employee’s check, you will need to select the deduction type from the drop down box. After selecting the type you will then need to enter the dollar amount of the deduction and the deduction cycle (i.e. daily, weekly, monthly, etc). If there is a particular start or end date, those should be entered as well. A separate entry will need to be made for each type of deduction. Please note: if Sedgwick is taking a 401k plan deduction, you have the option to select a deduction as a % of pay instead of an exact dollar amount.

Once you submit all the required information (including elective deductions, if applicable) you will be presented with a confirmation page and the information will be immediately sent to Sedgwick. At the same time, you will be sent a confirmation email. This confirmation email can also be stored or printed for your confirmation of the Employer’s Notice of claim filed and you may reply to the email if there are any corrections that need to be made to the information provided.

Sedgwick will load this information into their system during regular business hours only. It may take up to 4 business hours to load the data into the system. If you wish to provide additional information on this claim (or make a correction to the information you provided), you may do so by entering an Employer Claim Note in the Claim Data Input screen. (See "How do I enter an Employer Claim Note" for additional information).

To enter eligibility information on another claim, just click on Eligibility Input from the navigation bar to return to the list of all current claims that are missing employer data. The claim you previously entered will not be on the list, so the remainder of the claims listed, are those still needing employer eligibility information.
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Question : How do I Input an Employer Claim Note?
 
Answer :


The Employer Claim Note entry is located on the Claim Data Input screen. This should be used to supply information to Sedgwick that you want to be stored with the claim and that does not require a timely response back to you. If you need a timely response to a question regarding a claim, contact the Disability Benefit Specialist via phone instead.

To enter a claim note, just click Claim Input Data from the navigation bar to view a list of all current claims. Click on the claim for which you wish to enter the claim note, and the Claim Data Input screen will appear with the claim number you selected.

Enter your information in the Employer Claim Note section of the screen and click the Update Record button when you are ready to send the information to Sedgwick. Sedgwick will load this information into their system during regular business hours only. When the information is loaded in the system a notification will be sent to the Disability Benefit Specialist to alert them there is information from you to review on the claim.
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Question : How do I Input a Termination Date?
 
Answer :


The Termination Date entry is located on the Claim Data Input screen. Just click Claim Input Data from the navigation bar to view a list of all current claims. Click on the claim for which you wish to enter the Termination Date, and the Claim Data Input screen will appear with the claim number you selected.

Enter the Termination Date in the indicated field. When finished, click the Update Record button at the bottom of the page to submit the information to Sedgwick.

Sedgwick will load this information into their system during regular business hours only. When the information is loaded in the system, a notification will be sent to the Disability Benefit Specialist, alerting them that there is new information from you to review on the claim.
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Question : How do I inform Sedgwick of an employee’s Return to Work Date?
 
Answer :


The Return to Work Date entry is located on the Claim Data Input screen. Just click Claim Input Data from the navigation bar to view a list of all current leaves. Click on the claim number for which you wish to enter the return to work date, and the Claim Data Input screen will appear with the claim number you selected.

Enter the Return to Work Date in the indicated field. When finished, click the Update Record button at the bottom of the page to submit the information to Sedgwick.

Sedgwick will load this information (Active) and the claim has not been paid past the RTW date you entered, once Sedgwick loads the date into the system, the system will automatically change the Benefit Approved Thru Date to the date you have entered, and benefit payments will not be paid beyond that date. If the claim has been paid beyond the RTW date you entered, Sedgwick will not be able to load the date in the system and the Disability Benefit Specialist will review the claim for potential overpayment.
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Question : What is New Jersey Paid Family Leave (PFL)?
 
Answer :
New Jersey Paid Family Leave (PFL) is provided to New Jersey workers who suffer a wage loss when they take time off work to bond with a newborn or newly-adopted child or to care for a sick family member.
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Question : How does Paid Family Leave (PFL) differ from disability benefits provided to New Jersey employees?
 
Answer :
The disability program compensates workers who suffer a wage loss when they cannot work because of their own illness or injury. Paid Family Leave (PFL) provides wage replacement benefits to workers for a family member's illness or injury or to bond with a new child.
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Question : When will New Jersey Paid Family Leave (PFL) payments begin?
 
Answer :
Benefits will be payable for PFL claims commencing on or after July 1, 2009.
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Question : What is the New Jersey PFL benefit?
 
Answer :
The PFL benefit is the same benefit that the employee would be entitled to for disability benefits under the TDI program: The benefit provided under the State program (Family Leave Insurance) is two-thirds (2/3) of the employee’s average weekly wage up to the maximum amount payable. The benefits for PFL will be equal to or greater than those provided under the state FLI program. Your employer's benefits booklets or Plan Document will outline these benefits.
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Question : Who is eligible for New Jersey PFL benefits?
 
Answer :
Employees of all private and governmental employers subject to the New Jersey Unemployment Compensation Law are covered either by the state plan or their employer’s private plan.
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Question : Is New Jersey PFL employee or employer paid?
 
Answer :
The New Jersey Paid Family Leave program is financed 100% by worker payroll deductions. Employers do not contribute to the program. Please refer to the state’s website at http://lwd.state.nj.us/labor/ for information regarding the current employee contribution rate and taxable wage base.
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Question : Are payroll deductions mandatory for New Jersey PFL?
 
Answer :
Yes. Beginning January 1, 2009, employers are required to deduct the PFL contributions from the wages of employees who are covered by the program, unless the contributions are paid by the employer.
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Question : When do New Jersey PFL contributions begin?
 
Answer :
Contributions began on January 1, 2009
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Question : What is the contribution rate for New Jersey PFL?
 
Answer :
Please refer to the state’s website at http://lwd.state.nj.us/labor/ for information regarding the current employee contribution rate and taxable wage base. Wages in excess of the taxable wage base maximum are exempt from PFL withholding.
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Question : How many weeks can an individual collect New Jersey PFL?
 
Answer :
An individual may receive up to 6 weeks of benefits in a 12-month period, unless stated otherwise in the employer’s plan document.
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Question : Will there be a waiting period for New Jersey PFL?
 
Answer :
Yes. The first seven consecutive days of a claim is called the waiting period. If benefits are payable for any period during each of the three consecutive weeks following the waiting period, then benefits are also payable for the waiting period.

In the case of intermittent family leave, in a single period of family leave taken to provide care for a family member with a serious health condition, PFL benefits are payable with respect to the first day of leave taken after the waiting period and each subsequent day of leave during that period of family leave. If benefits become payable on any day after the first three weeks in which leave is taken, then benefits will also be payable for any leave taken during the waiting period.

Exception: There is no additional seven-day waiting period for a PFL claim for benefits to bond with a newborn when the PFL claim is for the period immediately following a Temporary Disability Insurance (TDI) pregnancy-related claim.
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Question : Can my employer require me to use accrued, but unused vacation?
 
Answer :
Yes. The employer of a claimant may require the claimant, during a period of family leave, to use up to two weeks of paid sick leave, paid vacation time or other leave at full pay. This option does not relieve employers of any collective-bargaining provisions with respect to paid time off. Employees are permitted to take the paid time off during the waiting period.
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Question : How do I file a leave request?
 
Answer :
You will be able to file your leave request online or with a customer service representative. If your employer does not require you to file your leave request directly with them (very few do), then you may file with Sedgwick using the procedures described below:
To file your leave request online: Use our self-service online claim form on our website. Once your leave request is entered into our system, you will receive an email with your Sedgwick claim number.

To file your leave request by telephone: Call Sedgwick at the toll-free phone number listed on your benefits card. If you do not have your benefits card, you can call us on our main claims line at (818)591-2772. A customer service representative will take your leave request information over the phone, and provide you with additional information. Be sure to note the Sedgwick claim number provided to you.

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Question : What documentation will be required for a bonding leave request?
 
Answer :
PFL leaves for bonding will require supporting documentation such as a birth certificate, hospital discharge record, or certificate of placement forms for adoption.
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Question : How does the leave process work?
 
Answer :
You should first file your leave request with Sedgwick. Once you have filed your leave request, Sedgwick will contact your employer and obtain the employment information (your date of hire, employee status, etc.) that we will need to begin processing your leave. After Sedgwick has received the necessary information from you, your employer, and the physician (if applicable) your leave request will be assigned to an Examiner for review.
If you have requested a Short Term Disability (STD) leave for your own Serious Health Condition (SHC) or a Paid Family Leave (PFL) to care for someone else with a SHC, a determination resulting in an approval, denial, or request for additional information will be made within approximately 4 business days.
If your leave request is approved, you will receive your payment from either Sedgwick or your employer, depending on the payment schedule your employer has established with Sedgwick.
If your claim is denied, you will be notified in writing. If Sedgwick needs additional information, you will be contacted by telephone or letter, depending on the information needed. If you are not returning to work on your scheduled return to work date, the physician (if applicable), may call Sedgwick to report the extension, or you can download the appropriate Supplemental Certification Form.
If you download this form, fill out the top portion and have the physician complete the bottom section of the form, and either fax or mail it to Sedgwick.
Once Sedgwick has received your extension, we will review the extension and a determination resulting in an approval, denial, or request for additional information will be made within approximately 4 business days.
If you miss a payment and your claim is subsequently approved or extended, your current benefit amount will be combined with any benefits you were due from the prior period and paid to you in your next payment. Sedgwick makes every effort to approve and pay claims in a timely manner to avoid any disruption to the claimant. However, there are times when we are unable to approve and pay a claim on the scheduled payment period as determined by your employer. This could be caused by a delay in filing the claim, receipt of medical documentation or other required information. If this should happen, any amount owed will be paid on the next scheduled payment date.
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Question : How does Sedgwick get the physician's information for my leave request?
 
Answer :
If you are filing a new leave request and we have not received information from the physician for this leave, inform the physician to call Sedgwick immediately. The physician will need to supply Sedgwick with information regarding the Serious Health Condition (SHC). If the physician is unable to call, you can download the applicable Certification form for the physician to fill out. Fill out the top portion of the form and instruct the physician to fill in the remainder of this form and fax it to Sedgwick as soon as possible, to complete the filing process. If you are not returning to work on your scheduled return to work date, download the appropriate Supplemental Certification Form and fill out the top portion. Have the physician complete the form and either fax or mail it to Sedgwick in order to continue your benefit payments. Please Note: Filing does not guarantee you will receive benefits. You must first meet the criteria and provisions of your company's plan. For a copy of the plan document, please contact your benefits department.
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Question : Can Sedgwick contact the physician to get the necessary information to process my leave request?
 
Answer :
If you are experiencing difficulty having the physician provide information to Sedgwick, please contact us with the physician's fax number and we can fax a form to their office in an attempt to obtain the required objective medical information. If your employer has established procedures with Sedgwick to call the physician upon initial filing, we will phone the physician for you.
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Question : What happens if Sedgwick cannot get information from the physician?
 
Answer :
If you have requested assistance in obtaining medical information from the physician, Sedgwick will assist you. However, if we are unable to obtain the necessary medical information from the physician, it is ultimately your responsibility. If Sedgwick does not receive objective medical information to support your leave request, your leave cannot be approved.
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Question : How do I know if Sedgwick received the fax I sent?
 
Answer :
Sedgwick logs in all faxes received and they can be found in the Document Delivery screen.
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Question : What should I do if I return to work earlier than my original expected return to work date?
 
Answer :
Contact Sedgwick immediately, and inform us of your early return to work date.
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Question : Kaiser is the medical provider. What do I need to do differently?
 
Answer :
Kaiser needs a signed Medical Release from you or the patient before they will provide Sedgwick with medical certification for your leave request. There are three options for providing this to Kaiser: 1. A hand-written note with your signature or the patient's signature and date authorizing them to release information to Sedgwick 2. The Kaiser Release of Information form given to you or the patient by Kaiser at each visit The Sedgwick Release of Information Form, which you will receive from Sedgwick after filing your leave request (or one can be downloaded directly from our website). Be sure to take this important step of providing Kaiser with a release as soon as possible, as the Kaiser Disability Office will not release information without one of these forms. (Most Kaiser locations will accept a fax.) To assist the Kaiser Disability Department in providing medical certification, you may also provide them with a Certification Form for Initial Certification of Disability (Physician's Certificate) at the time you provide them with the medical release form. You may also ask them to phone in the certification by having them call the toll-free 800 number for Sedgwick (this method is the quickest way to expedite your claim). If they will not call Sedgwick, follow the steps listed above. Continue to follow up with the Kaiser location until you are assured that the forms have been completed and sent to Sedgwick. You can check the status of your leave request by going to our Claimant Home Page, and clicking "Check the Status of Leave". Just follow the easy instructions for registering to see all details of the status of your forms and leave information. If you are planning a future leave request (e.g. pregnancy, surgery, bonding), you can expedite your leave request by downloading and printing the Physician's Certificate and Release of Information forms ahead of time and taking them to the Kaiser Disability Office. Kaiser's website is: www.kaiserpermanente.org
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Question : How long will it take to process my extension request for my leave?
 
Answer :
It is Sedgwick's goal to process an extension of a leave request within 4 business days from the time the completed extension is received. You can check the status of your existing leave by accessing the Check Leave Status page. Occasionally there is a need for additional medical records. If additional medical records are required to make a decision regarding your request for extension, the physician's office will be contacted within 4 business days.
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Question : Why didn't Sedgwick approve my leave to the date the physician requested?
 
Answer :
Sedgwick reviews the information provided by the physician and determines if there is medical evidence to support your leave request. If the physician has indicated you will be away from work beyond normal guidelines for the Serious Health Condition (SHC), Sedgwick will approve your leave to a certain date, and re-review your leave request when that date arrives (to see if the additional time is supported).
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Question : What do I have to do during my leave?
 
Answer :
You have a very important role in the process. To ensure you receive the leave time that you are entitled to, you must:
- Sign and return all forms to Sedgwick as soon as possible
- Stay in touch with Sedgwick and your Supervisor; provide information as requested
- Return to work when your leave ends
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Question : How long will it take to process my leave request?
 
Answer :
Once you file your leave request with Sedgwick, it will be processed within approximately 4 business days from the time we receive all necessary information. You can help speed up the process by doing the following: Sign and return to Sedgwick all forms as quickly as possible Ensure the physician immediately provides Sedgwick with the medical information requested Stay in touch with Sedgwick throughout your leave
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Question : How much can I expect to receive for New Jersey PFL benefits?
 
Answer :
The actual amount of your PFL payment is determined by several factors:
  • The percentage of replacement income your plan specifies (this will most likely be the same as the state program of two-thirds (2/3) subject to the state weekly maximum amount; or it may be based on length of service, or other requirements in the plan)
  • Income received from other sources could be deducted from your gross benefit amount
  • Your employer may have made arrangements for Sedgwick to pay your health insurance, 401K, etc. while you are disabled, (this would be deducted from your payment)
  • Taxes could be withheld if you are covered under a taxable plan.
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    Question : When will I actually receive my benefits?
     
    Answer :
    Sedgwick wants you to receive the benefits for which you may be eligible as quickly as possible. Review of your claim will be performed in approximately 4 business days from the time we receive all necessary information. Sedgwick will make every effort to obtain the required objective medical information from the physician. You can help speed up the process by doing the following: Sign and return to Sedgwick all forms as quickly as possible. Ensure the physician immediately provided Sedgwick with the medical information requested Stay in touch with Sedgwick throughout your leave. If your leave request is approved, you will receive your payment from either Sedgwick or your employer, depending on the payment schedule your employer has established with Sedgwick.
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    Question : When will PFL benefits end?
     
    Answer :
    PFL payments could end due to any of the following situations:
  • The care recipient no longer requires care
  • The employee has reached the maximum benefit amount or time allowed under the Plan (see your benefits booklet or Summary Plan Description to find out the applicable provision)
  • The employee has returned to work
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    Question : Will deductions be taken from a benefit payment?
     
    Answer :
    Depending on the plan under which the employee is covered, some of the deductions that could be taken from benefit payments include:
  • Taxes
  • Health Insurance
  • Other Income/Benefits
  • 401K
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    Question : May an employer require employees to take all 6 weeks of PFL at once?
     
    Answer :
    If the leave is to care for a seriously ill family member, the leave may be taken during one continuous period, up to a maximum of six (6) weeks or intermittently up to a 42 day maximum in a 12-month period.
    If the leave is to bond with a newborn or newly adopted child, the leave must be taken during one continuous period of time unless both the employee and the employer have agreed to an intermittent leave schedule. In those cases, leave may be taken in non-continuous intermittent periods of seven (7) days or more. All leave taken to bond with a newborn or newly adopted child must be taken during the 12-month period immediately following the birth or adoption of the child.
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    Question : Does New Jersey PFL offer job protection?
     
    Answer :
    The Paid Family Leave program does not protect anyone's job. The program provides partial wage replacement when an employee cannot work because of the need to care for a child, parent, spouse, or domestic partner, or to bond with a newborn or newly adopted child. Some employees may have their job protected under other laws, such as the federal Family and Medical Leave Act (FMLA) or the New Jersey Family Leave Act (NJFLA).
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    Question : How is the New Jersey PFL benefit affected if the employee receives sick leave benefits and PFL at the same time?
     
    Answer :
    Paid Family Leave benefits are not payable for any period the claimant/care provider is receiving New Jersey Temporary Disability Insurance Benefits, Unemployment Compensation Benefits, Workers' Compensation Benefits, or benefits from a disability or cash sickness program or similar law of any state or the federal government including, but not limited to, Social Security Disability benefits.
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    Question : Are New Jersey Paid Family Leave (PFL) benefits taxable?
     
    Answer :
    New Jersey Paid Family Leave benefits are subject to withholding of Federal income taxes and FICA taxes (Social Security and Medicare). They will not be subject to withholding of New Jersey state income taxes. If Sedgwick pays your Paid Family Leave benefits, a form W-2 will be issued for these payments and will be sent by January 31st following the end of the taxable year.
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    Question : How does Sedgwick obtain my tax status?
     
    Answer :
    If Sedgwick is providing you your benefit payments (versus your employer making the payment), we will attempt to obtain your W4 information directly from your employer prior to your first payment. If we do not receive the W4 information at the time your PFL claim is approved, your payment will default to a status of single with zero allowances in order to expedite the payment of your claim. If you wish to provide Sedgwick with your current or updated W4 information please fax to Sedgwick a signed form W4 (and be sure to include your claim number). Our fax number is 818-591-7664. You can download the current W4 form by clicking on the following link: http://www.irs.gov/
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    Question : What if my employer pays my PFL benefits rather than Sedgwick?
     
    Answer :
    If your employer pays your PFL benefits, then your employer will be responsible for withholding and reporting taxes from your PFL benefits. Your employer will also issue a form W2 reflecting your PFL benefits.
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    Question : Why could my benefit payment be late?
     
    Answer :
    Sedgwick has not yet received information supporting your leave request Information received by Sedgwick is incomplete and/or Sedgwick needs additional information on your leave request The necessary information was received after the normal payroll cycle had run A waiting period may apply to your leave request Please note: If you miss a payment and your leave request is subsequently approved, your current benefit amount will be combined with any benefits you were due from the prior period and paid to you in your next payment.
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    Question : Why haven't I been paid from the first date of my leave request?
     
    Answer :
    Some plans have a waiting period that must be satisfied before benefits are payable. In order to find out if your plan has a waiting period and what that waiting period consists of, please refer to your benefits booklet or summary plan description.
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    Question : What is self-insurance or self-funding?
     
    Answer :
    Self-insurance is the method used by employers who wish to assume responsibility for financing of their disability payments with employer or employee monies rather than pay premiums to an insurance company for this coverage.
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    Question : What is a Third Party Administrator (TPA)?
     
    Answer :
    A TPA is a professional organization hired to provide plan administration for client employees and their benefit plans. Typical duties include:
    • Processing Claims
    • Paying Providers
    • Providing Benefit & Eligibility Information.
    These are just a few of the administrative duties that a Third Party Administrator performs.
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    Question : What are the requirements to establish a private plan in Puerto Rico?
     
    Answer :
    The employer can establish a "Private" plan if they meet the following requirements:
    • The plan must offer benefits at least equal to the Public TDI plan;
    • The employer can charge employees the same rate or a lower rate than the Public TDI mandated plan, but may not charge more than the mandated plan rate. If significant benefit improvements are offered, the employer may charge the employees for a reasonable portion of the additional cost so long as the employee cost does not exceed the employer cost;
    • The employer must receive the one-time consent of a majority of the employees (50% plus 1) for the plan to go into effect at which time all current and all future employees are covered by the self-insured plan (there are no exceptions); and
    • The employer must provide a surely bond in an amount equal to one-half (1/2) of the annual expected employee contributions to the plan.
    If the sum of all costs (claims and expenses) exceeds the employee contributions (a maximum of 0.3% of the first $9,000 of annual earnings), the employer is required to put in sufficient funds to cover the short fall.
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    Question : What is the Puerto Rico TDI background?
     
    Answer :
    Background:
    The bureau of Employment Security operates the mandated program.

    Plan participation
    The Puerto Rico Public Disability Insurance Law (TDI) requires that all employees working in the Commonwealth of Puerto Rico (except for government employees and certain tax-exempt organizations) must participate in an audited and regulated short-term disability income replacement plan. Employers may satisfy their obligation to make this coverage available to their employees in one of three ways:
    • They may have their employees participate in the Public TDI plan.
    • They may have an Insurance Company provide a "Private" insured plan to their employees.
    • They may establish a "Private" self-insured plan to provide coverage to their employee.
    If an employer has their employees participate in the Public TDI plan operated by the Bureau of Employment Security, the employees must accept the benefits provided by the plan, accept the plan administration provided by the Bureau of Employment Security, and pay the required costs.
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    Question : What is the Puerto Rico TDI benefit formula?
     
    Answer :
    Benefits are paid weekly, are partially taxable and provide an income replacement of 65% of an employee's average weekly pay up to a minimum benefit of $12.00 and a maximum weekly benefit of $113.00. Benefits for agricultural employees are limited to $55 maximum per week.

    Benefits commence on the eighth (8th) consecutive day of disability (retroactive to the first day of disability if the disabled person is hospitalized) and continue for up to a maximum of 26 weeks. The maximum weekly benefit is recalculated annually and is a function of the statewide average weekly wage. There are additional benefits for death and dismemberment.
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    Question : What are the Puerto Rico TDI plan costs?
     
    Answer :
    The combined employee and employer contribution maximum is 0.6% of the first $9,000 of annual earnings ($54.00/year). The contributions may be shared as long as the employer portion is not less than the employee portion.
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    Question : What services does Sedgwick provide employers and their employees?
     
    Answer :
    Sedgwick offers a broad spectrum of services to the absence and disability benefits market, including:
    • Self-Insured Short-Term Disability Administration
    • Self-Insured Long-Term Disability Administration
    • Self-Insured Statutory Disability Administration
    • Family and Medical Leave Services
    • Sick Pay/Salary Continuation Administration
    • Integrated Disability Management
    • Integrated Health and Disability Management
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    Question : Are alternative plans permitted in Rhode Island?
     
    Answer :
    No alternative plans are permitted.
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    Question : What is Rhode Island's State Plan Background?
     
    Answer :
    Background:The State of Rhode Island Disability Program has been in effect since the 1940s. The Department of Employment and Training administers the plan.

    State plan

    The plan is operated by the state only with no alternative plans allowed. Employees pay the full cost of the state plan (no employer contribution required).
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    Question : What is the Rhode Island TDI benefit formula?
     
    Answer :
    Please refer to the state’s website at http://www.dlt.state.ri.us/ for information regarding the current weekly minimum and maximum benefit amounts.

    Eligible employees must have earned at least $8,800 in 4 out of 5 preceding Base Period Quarters. If the employee fails to qualify on this basis, he/she must meet all of the following requirements:
    • must have earned $1,480 or more in one of the Base Period Quarters, and
    • must have earned at least 1 1/2 times the amount of the highest quarter earnings, and
    • must have earned Base Period wages of at least $2,960.
    Benefits begin on the eighth (8th) consecutive day of disability (retroactive to the first day if the disability lasts longer than 28 days or if disability caused a denial of unemployment compensation benefits). Benefits last for up to 30 weeks in any given benefit year. Employees are eligible for an additional benefit of the greater of 7% of their weekly rate or $10.00 for each child under age 18. This benefit is referred to as the "Dependent Award".
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    Question : What are the Rhode Island TDI plan costs?
     
    Answer :
    The Rhode Island Temporary Disability Insurance Plan is financed 100% by worker payroll deductions. Employers do not contribute to the program. Please refer to the state’s website at http://www.dlt.state.ri.us/ for information regarding the current employee contribution rate and taxable wage base.
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    Question : How do we start a Hawaii private plan?
     
    Answer :
    The establishment of a self-insured Hawaii private plan can have significant advantages for both the employees and employer. Sedgwick prepares a comprehensive self-insured Hawaii TDI Feasibility Study for our prospective clients (without any cost to the employer). We will not only determine whether or not your company is a good candidate for self-insuring, but will also quantify the specific savings your company can expect by establishing a self-insured Hawaii TDI plan for your employees.

    1. Gather Data
    • Current employment census

    • Provide Sedgwick with copies of the "Quarterly Contributions Reports" (State form UC-B6) for 1998 for each corporation with employees in Hawaii

    • Number of TDI claims filed by Hawaii employees (per corporation) in the last 12 months


    2. Sedgwick Prepares Comprehensive Feasibility Study
    • Economic Considerations

    • Recommendations and a schedule for implementation, if feasible
    3. Decision to create a self-insured Hawaii TDI program and selection of Sedgwick as your disability administrator

    4. Implementation

    • Sedgwick recommends benefit designs that will satisfy both State requirements and employees
    • Sedgwick designs plan documents, posters, claim filing processes, claim checks, manuals, reports, and other forms
    • Sedgwick assists employer in securing approval of applications to the State
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    Question : What are the advantages to self-insuring Hawaii TDI?
     
    Answer :
    • No state premium tax
    • Lower retention costs
    • Improved cash flow
    • Lower overall costs
    • Simplified administration
    • Close coordination with other benefit sources
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    Question : What are the alternative plan options in Hawaii?
     
    Answer :
    The State oversees the application process when moving from an insured program to a self-insured program. An insured policy must be in place before self-insurance will be granted. If the self-funded alternative is used, the employer must state the location of the claims paying facility. If self-funding, the employer must also submit a copy of their annual financial report. The State may require a surety bond depending upon the employer's financial status.

    No employee enrollment is necessary. All employees must be covered by the private insured or self-insured plan provided by the employer (except for government and enumerated special employment situations). Individual employees may not opt out of the plan.

    Employer payroll records and plan claim records are subject to audit.
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    Question : What are the Hawaii plan costs?
     
    Answer :
    The employee is required to contribute up to one-half (1/2) of plan costs, but no more than 0.5% of average weekly earnings or $4.10 per week, whichever is less. Please refer to the state’s website at http://hawaii.gov/labor for the current taxable wage base. The employer is required to pay for one-half (1/2) or more of the plan costs, plus any additional costs not chargeable to the plan.
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    Question : What are the requirements to establish a private plan in Hawaii?
     
    Answer :
    If an employer determines their insured Hawaii TDI Plan provides a poor cost/benefit ratio for their company and it would be advantageous for their company to establish a self-insured private plan, the employer can establish such a plan if they meet the following state requirements:
    • The employer must provide a plan that offers benefits at least equal in all respects to the state plan TDI requirements.
    • The employer may charge the employees the TDI contributions allowed under the TDI law (or less), but may never charge the employees more than the state law allows.
    • An insured policy must be in place before self-insurance will be granted.
    • The employer must state the location of the claims paying facility.
    • The employer must also submit a copy of their annual financial report. To self-insure TDI, the State may require a surety bond depending upon the employer's financial status.
    • No employee enrollment is necessary. All eligible employees must be covered by the private insured or self-insured plan provided by the employer (except for government and enumerated special employment situations).
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    Question : What is the Hawaii benefit plan formula?
     
    Answer :
    Minimum benefits are determined to be 58% of average weekly earnings, but not more than the maximum weekly benefit amount annually set by the Disability Compensation Division. Please refer to the state’s website at http://hawaii.gov/labor for the current minimum and maximum weekly benefit amounts. Benefit entitlement commences on the eighth (8th) consecutive day of disability and continues for up to a maximum of 26 weeks while the claimant remains disabled.

    The definition of wages is determined for individual claimants using the earnings in the week before the commencement of disability (salaried) or the amount that would have been paid as wages but for the commencement of disability (hourly). The maximum benefit is determined annually based on statewide average earnings. Benefits are taxable for Federal and State Income Tax, and FICA in proportion to employer/employee contribution rates.
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    Question : What's needed for Hawaii TDI program participation?
     
    Answer :
    The State of Hawaii does not have a State Fund and does not administer Disability benefits, except in an oversight capacity. The Department of Labor and Industrial Relations administers the TDI Program. The Hawaii Plan covers all employers with one or more employees.
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    Question : What are New York's DBL plan benefits?
     
    Answer :
    Benefits are paid weekly, and are partially taxable (depending on the ratio of employer/employee contributions) equal to 50% of the average weekly wage of the employee over the last four weeks prior to disability with a minimum weekly benefit of $20.00 and a maximum benefit of $170.00.

    Benefits become payable on the eighth (8th) consecutive day of disability and last while the disability continues for up to 26 weeks. The maximum benefit of 26 weeks is either per disability or during any consecutive period of 52 weeks.
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    Question : What are New York's DBL plan costs?
     
    Answer :
    The employee contribution rate is one-half (1/2) of one percent (0.5%) of the first $120.00 of weekly wage up to a maximum of $.60 per week ($31.20 per year). The employer contributes the remainder of plan costs (if any).

    The IRS has ruled the employer contributions to the state plan or to a private plan are deductible by the employer and considered taxable income to the employee. Employee contributions to the State Fund are deductible as State Taxes, while contributions to a private plan are treated as nondeductible personal expenses.
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    Question : What are the requirements to establish a New York DBL private plan?
     
    Answer :
    If an employer decides to implement a self-insured "Private" plan, the plan and the employer must meet the following requirements: The employer must have an insurance policy in place before self-insurance will be granted; No employee consent or enrollment is necessary; The plan must offer benefits at least equal to the state mandated DBL benefit; The employer can charge the employees the same or less than the DBL mandated contribution level, however, employees can not be charged more unless there have been improvements in coverage, in which case a higher contribution may be permitted. The employer must agree to cover the balance of the DBL level of plan costs that are in excess of employee contributions; The employer must agree to provide a guarantee bond, if so required by the state; and The employer must agree to pay all obligations, including benefits, fines, expenses, and assessments imposed pursuant to the DBL.
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    Question : What is New York's insured plan option?
     
    Answer :
    If the employer has their employees participating in an insured plan, the insured plan must offer at least the "Statutory" benefits dictated by the New York DBL. Employees must pay the required contributions to the plan (unless the employer assumes that obligation). The employer pays any additional premium that may be required by the insurance company to pay for incurred claims expenses and insurance company administration costs.
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    Question : What is the New York Disability benefits law background?
     
    Answer :
    Established in the 1940s, The New York Disability benefits Law (DBL) requires that all employees working in New York (except for government employees and certain tax-exempt organizations) must participate in a state approved short-term disability income replacement plan. The Disability benefits Law is administered by the New York Workers' Compensation Bureau. Employers may satisfy their obligation to make this coverage available to their employees in one of two (2) ways:
    • They may use an insurance company to provide the DBL coverage to their employees
    • They may establish a "Private," self-insured DBL plan
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    Question : What are the New Jersey plan costs?
     
    Answer :
    Please refer to the state’s website at http://lwd.state.nj.us/labor/ regarding the current employee contribution rate and taxable wage base information. Employer contribution rates vary depending upon their experience rating. Please refer to the state’s website at http://lwd.state.nj.us/labor/ regarding the current employer contribution rates.

    In New Jersey, TDI costs are determined based on the claim experience of the individual employer. Employee claims are charged to the unemployment disability fund against the employer's account based on the onset of the disability. If the onset of disability is more than two weeks following the last day the employee worked at a company, the claim is charged to the overall State Fund.

    The statewide rate is determined annually and reflects the reserves in the State Fund in conjunction with the revised maximum benefit payable as determined by the statewide average weekly wage.

    Employee claims are attributed to the employer's account. The result of the employer and employee contributions, less employees' claims over a 3 to 5 year period, determine the "Reserve Balance Percentage" and the employer's next year's contribution rate within the minimum and maximum rate range determined for the state plan.

    The IRS has ruled the employer contributions to the state plan or to a private plan are deductible by the employer and considered taxable income to the employee. Employee contributions to the State Fund are deductible as State Taxes, while contributions to a private plan are treated as nondeductible personal expenses.
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    Question : What are the requirements to establish a private plan in New Jersey?
     
    Answer :
    The employer can establish a "Private" plan if the following state requirements are met:
    • The plan must offer benefits at least equal to the state plan;
    • The employer can charge employees the same rate or a lower rate than the state plan, but may not charge more than the state plan rate;
    • The employer must receive the one-time consent of only a majority of the employees (over 50%) for the plan to go into effect at which time all current and all future employees are covered by the self-insured plan (individual rejection of the plan is not allowed). NOTE: If the plan is noncontributory (i.e., totally employer paid), no enrollment is required.
    • The employer must provide a surety bond in an amount equal to one-half (1/2) of the annual expected employee contributions to the plan. The bond requirement may be waived by the state on a case-by-case basis if the financial status of the employer is strong.
    • The employer must agree to pay all obligations, including benefits, fines, expenses, and assessments imposed pursuant to the TDI.
    Only if the sum of all costs (claims and expenses) exceeds employee contributions is the employer required to put in sufficient funds to cover the shortfall.
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    Question : What are the results of participation in the New Jersey state plan?
     
    Answer :
    If an employer has their employees participate in the state plan, the employees must accept the benefits provided by the state plan, accept the plan administration provided by the state, and pay the required costs. The state plan is experience rated by employer and the employer portion of plan costs will vary depending on the claims experience of the work force for each employer. The state plan covers all employers with one or more employees.
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    Question : What is the New Jersey benefit formula?
     
    Answer :
    Benefits are paid weekly, and are a taxable income replacement benefit of 66 2/3% of the employee's average weekly pay up to a maximum weekly benefit amount. Please refer to the state’s website at http://lwd.state.nj.us/labor/ for the current weekly maximum benefit amount. Benefits are taxable under Federal, State, and FICA income tax programs in proportion to the employer/employee contribution rates. Benefits commence on the eighth (8th) consecutive day of disability (retroactive to the first day of disability if the disability is over 21 days in duration) and continue for up to a maximum of 26 weeks while the claimant remains disabled. An employee must have earned at least $143 per week for 20 weeks during the base year or have earned $7,200 during the base year in order to qualify for benefits.
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    Question : What are the California plan costs?
     
    Answer :
    The cost of California SDI is paid entirely by employees unless the employer gratuitously elects to assume some or all of the costs on behalf of their employees.

    For information regarding the current SDI contribution rate and taxable wage limit, please refer to the state’s website at http://edd.ca.gov/ . The rate is adjusted annually depending upon the financial condition of the State Fund. There is no experience rating by employee or employer group. The overall condition of the State Fund determines the tax rate for all participants. .

    The IRS has ruled the employer contributions to the state plan or to a private plan are deductible by the employer and considered taxable income to the employee. Employee contributions to the State Fund are deductible as State Taxes, while contributions to a private plan are treated as nondeductible personal expenses.
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    Question : What are the results of participating in the California state plan?
     
    Answer :
    If a company has their employees participate in the state plan, their employees must accept the benefits that are provided by the state plan and they must pay the required costs unless the employer voluntarily elects to pay all or part of the State Disability Insurance (SDI) contribution to the state plan on behalf of their employees. (This results in a Federal and state requirement for the employer to impute this contribution income for the employees on their W-2s at year-end.)
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    Question : What is the California benefit formula?
     
    Answer :
    The state plan provides a tax-free replacement of income of 55% of an employee's average weekly pay (benefits are paid biweekly) up to a maximum weekly benefit amount. Please refer to the state’s website at http://edd.ca.gov/ for the current maximum weekly benefit amount. Benefit entitlement commences on the eighth (8th) consecutive day of disability and continues for up to maximum of 52 weeks while the claimant remains disabled. Benefit entitlement and award level is based on the trailing wage average of covered wages earned in California. It is possible for a person new to California or for a person who has not been in the work force for a prolonged period, to be ineligible for benefits due to absence of wage credits in the State Fund wage bank.

    The SDI maximum weekly benefit is indexed to the Temporary Total Disability Benefit under workers' compensation. In turn, the workers' compensation weekly wage benefit is targeted at a specified replacement ratio of the average wages earned in the state in the prior year.
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    Question : How many states provide statutory disability programs?
     
    Answer :
    There are five states plus the Commonwealth of Puerto Rico that currently provide statutory disability programs. All except Rhode Island, permit employers to self-insure and use a plan administrator, such as Sedgwick.

    For self-insurance to make financial sense, a company generally should have a minimum of 500 employees and usually 1,000 or more workers. This varies by state, depending on several factors, including benefit Plan design and contribution rates.

    State disability programs are separate and different from the better-known State Workers' Compensation programs in that state disability Plans cover workers who become disabled for non-work related accidents or illnesses. Typically, the most frequent type of claim in a state mandated plan involves maternity.
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    Question : Why self-insure state disability?
     
    Answer :
    Self-insuring statutory disability insurance is probably the most advantageous step an employer can take to reduce overall benefit expenses. Self-insuring allows the employer to have a single, consistent, nationwide STD program for all employees and eliminates the duplicate costs for coverage under any concurrent or simultaneous program.
    • Lowers overall retention costs of insured plan by at least 50%.
    • Lack of early intervention and case management increases length of state benefits by 25% or more.
    • Supplemental employer paid benefits are typically provided for the same period and duration as the state benefits.
    • State benefits (and workers' compensation) are primary to all other Disability benefits. Benefits must be integrated with sick pay or salary continuation programs on a prospective or retrospective basis.
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    Question : What are the end results of Sedgwick's Health & disability model?
     
    Answer :
    The results of our approach confirm our belief that we can reach employees much earlier in the disease process and reduce both excessive lost time from work and impact escalation into more chronic disease states, costs, and treatment through coordinated intervention and care.

    To date, we have found that approximately 15-25% of all incoming lost time cases (typically non-work related) are "flagged" for more intensive review and management. Application for lost time benefits is now considered an entry point into the health care system. Of those flagged events, 10% result in very intensive case management interventions provided by vendor partners. This means that medical managers, vocational experts, and behavioral care staff are jointly involved in assessing the patient cases and identifying clinical pathways and/or community-based resources to help with recovery.

    What we have found most gratifying is that from a health care perspective, 80% of the case management interventions were cases that would not have been identified through traditional measures. On those cases, we have been able to save hundreds of days in lost time and seen much improvement in our cost per case rates.
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    Question : What are the key features of Sedgwick's FML Service offering?
     
    Answer :
    • Toll free, single call intake of leave and disability claim data.
    • Capability to administer and coordinate all Federal, State leave entitlements and employer programs.
    • The system is designed with the flexibility to handle the administration of varying employer leave practices and plans.
    • Preparation and delivery of all notices, letters and required forms for complete leave administration.
    • Employee communications are customized for each client
    • Adherence to employer specific certification criteria.
    • RN review of medical certifications and recertifications available when requested by employer (optional).
    • E-mails to employer HR Staff and employee's supervisor enhance communication and coordination of leave management efforts.
    • Generation of standard and custom reports to management including weekly, monthly and yearly transaction reports where indicated and an annual absence management summary.
    • Supervisor training programs conducted on client premises, or group training seminars available at our office (both optional)
    • Tracking of all intermittent and reduced leave episodes.
    • Leave is tracked based upon the calendar year, a fixed date, roll forward, or a roll backward leave cycle.
    • Leave can be tracked in 12 or 24 month leave cycles, or any other leave length cycle, as is required by specific leave entitlements.
    Sedgwick's leave tracking service is designed to operate in conjunction with our Disability Claim Management System. Now an employee will be able to make one toll free phone call to initiate a claim for Disability benefits and to start the leave process. Using our advanced systems, the employee, his or her supervisor and other designated staff will be able to receive the current status of a disability claim and/or a leave episode throughout the administration process.
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    Question : What do our clients have in common?
     
    Answer :
    Sedgwick's clients represent a diverse set of industries and businesses, yet they all share certain characteristics:
    • Size -- our clients are all large employers (typically 3,000+ employees)
    • Multi-Site -- our clients have numerous locations and frequently operate in a multi-state environment
    • Risk Tolerance -- our clients understand the value in self-insurance
    • Customer Service -- our clients expect the highest possible customer service for their employees and their benefits staff
    • Partnership -- our clients know the value in partnering and how to work with vendors as partners
    • Quality -- our clients know their business depends on the quality of their products and services, and as their agent, we must also provide a level of quality consistent with their standards.
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    Question : What is FMLA?
     
    Answer :
    FMLA or Family Medical Leave Act is a Federal law enacted in 1993 which requires employers with more than 50 employees to provide eligible workers up to 12 weeks of unpaid leave for birth, adoptions, foster care placement, and illness of employees and/or members of their families. Many states have also passed leave laws that must be addressed in conjunction with the Federal FMLA.
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    Question : What is Sedgwick's FML Service?
     
    Answer :
    Sedgwick's FML Service provides full tracking and reporting of leave episodes under Federal, State and client leave programs in all 50 states. FML Service features automated correspondence and e-mail delivery reflecting leave episode requests, extensions, and termination activities. Our FML Service is designed to keep the employer and employee informed, while significantly reducing the burden of detailed leave tracking and record keeping. Designed for the larger employer with multi-state operations, Sedgwick's FML Service administration starts with a pre-implementation inventory and review of all employer leave programs and practices.
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    Question : How does outsourcing work?
     
    Answer :
    According to a survey on productivity in benefits administration, 72% of participating companies indicated that human resources staff members spend more that 25% of their time, and that 28% spend more than 50% of their time, on routine administration matters.

    The various components of self-administered disability plans are often managed by several individuals, who may be in completely different departments within a company.

    When non-occupational disability plan management is outsourced, the administration of multiple plans (sick pay, salary continuation, and short-term disability) is organized into a single process. Early intervention begins when the claimant contacts the third party administrator, typically via a toll-free telephone number, to apply for benefits. The administrator would likely set up the claim immediately over the phone, prompting the claimant to provide the necessary information verbally instead of via a written claim form.

    Next, medical information would be gathered from the provider, and the case would be monitored by the disability management vendor, who also would act as an advocate for the process. Early intervention and careful monitoring of disabled workers throughout the disability period are keys to administrative success. With proper support early on, individuals will develop higher expectations, and schedules can be devised to return them to work as soon as possible, reducing the incidence and duration of long-term disability.

    This not only frees internal administrators to concentrate on their core competencies, it eliminates confusion over benefit coverage's and filing obligations for claimants. All aspects of claims processing are handled by the third party administrator who brings to the process objectivity, technology, and plan expertise that self-administered programs rarely, if ever, have. This system also ensures that return to work, clinical oversight, rehabilitation, and application of disability durations and of policy provisions are managed consistently.
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    Question : What are the advantages of a self-insured plan with Sedgwick as your administrator?
     
    Answer :
    • Online claim filing via www.sedgwickcms.com/calabasas
    • Paperless claim filing via 800#
    • Coordinated disability management
    • Integration with sick leave, STD, and LTD
    • Rapid claim response
    • Claim status for employee and employer -available 24/7
    • Employer/consultant design plan
    • Plan surplus may be used to offset costs of administration and fund other benefit programs
    • Increase in employee funded Disability benefits can reduce company funded sick leave costs
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    Question : What are the advantages of using Sedgwick's integrated disability model?
     
    Answer :
    The clients for whom Sedgwick's unique services are having the greatest impact (from both a cost and an ease of administration standpoint), are our fully integrated sick pay/salary continuation, SDI, STD, and LTD clients.

    Many of our fully integrated clients are achieving annual disability benefit costs of less than 1% of their annual payroll. Compare this to a national average of 4-to-5% of payroll as the norm, and the advantage of having a fully integrated disability benefit program is clear.

    Sedgwick's unique capability to combine self-insured state disability Insurance (SDI) plans with company sponsored sick pay/salary continuation, STD, and LTD Plans into a single, simple integrated disability benefit plan for all employees in all states has been in operation since 1980 when Sedgwick designed its first fully integrated program for Union Bank.

    New and existing clients can benefit from our integrated, pre-tax employee contribution disability benefit plan which not only greatly simplifies the disability benefit claim process for employees and employers, but also eliminates the problem of overpayment of net Disability benefits when a portion of the integrated benefit is totally (i.e. California SDI) or partially (i.e. Hawaii, New Jersey, New York and Puerto Rico) tax free.

    An example of a fully integrated sick pay/salary continuation, SDI, STD and LTD client is Charles Schwab Corporation. Their integrated disability benefit includes Sedgwick's newest innovation of reducing the required employee SDI contributions in California, Hawaii, New Jersey, New York and Puerto Rico by making the required employee SDI contributions part of the employer's pretax criteria/flex plan.

    Under the Schwab Plan, the employees are able to pay a single pretax contribution for their entire SDI, STD and LTD program, plus they are able to select the level of disability coverage, under these combined plans, that suits their particular family needs. This program allows Schwab employees to have a single integrated disability benefit program that is the same for all employees in all states plus allows Sedgwick to combine their sick pay/salary continuation benefit with their self-insured SDI and STD benefits in a single, fully taxable benefit check.

    Finally, Sedgwick separated the self-insured SDI plans from the state SDI employee contribution requirements and the multiple employee payroll deductions that are required for separate SDI/STD/LTD programs.
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    Question : What are the advantages to pre-tax deductions for mandated state disability programs?
     
    Answer :
    Self-insuring the mandated state disability Insurance (SDI) programs in California, Hawaii, New Jersey, New York and Puerto Rico allows the employer to have the employee contributions to these plans paid by pretax deductions rather than after tax-deductions This allows employers to do the following:
    • Lowers the cost of the employees SDI contributions by 25-to-50%, depending on the tax bracket of each employee.
    • Eliminates the net pay windfall that employees enjoy while disabled if the employer supplements the tax-free SDI payments with taxable payments from sick pay/salary continuation or STD programs.
    • Allows Sedgwick to combine the SDI payments with the supplemental sick pay/salary continuation or STD payments into a single benefit check paid directly to the employees at their home or through their employer's payroll system.
    • Allows the employer to have the same cost and same benefits in all States, regardless of whether the employee is in a mandated SDI State or not. One "Income Protection Plan" for SDI, STD, and LTD.
    If desired, this program allows Sedgwick to remove all disability benefit payment responsibility from the Company Payroll Department after the employee is disabled for more than 5 work days As an alternative, Sedgwick can calculate the benefit payments (less offsets) and electronically feed the payment data to the employer's payroll department. Sedgwick will be responsible for integration of the benefit with Workers' Compensation benefits, Third-Party Awards, Social Security Benefits, and FMLA, etc. Again, no payroll (if desired) or benefits involvement. If desired, Sedgwick will also be responsible for withholding from the employer's benefit checks all elective deductions (pretax and after-tax) that are required for the employee to maintain his or her benefit coverage while on disability. If desired, Sedgwick will also withhold all Federal and State taxes, based on employee W-4 status, and deposit these withheld taxes plus employer payroll taxes on a timely basis under a separate Tax I.D. number. A separate W-2 will cover all Disability benefits.
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    Question : What are the differences between a self-funded and an insured disability plan?
     
    Answer :
    Self-funded plans have several advantages over insured disability plans. One of the main advantages is the flexibility of the Plan design. By creating an ERISA program, you can design the plan to meet your needs.

    Insured plans are state regulated and must conform to standard existing Plan designs. Employers can experience greater cash flow savings through flexible funding options and control of short-term cash flow. A self-funded plan also allows employers to earn investment returns on funds set aside to cover annual claims. Funds spent on insurance premiums usually have no investment return.

    Insurance is not risk free -- increased costs are eventually passed on through premium taxes or additional overhead built into premiums. Administration costs are generally lower in self-funded plans because you pay actual fees as you go rather than an estimated fee based on the potential duration.
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    Question : What are the hidden costs of disability?
     
    Answer :
    The annual costs associated with employee disabilities are estimated at over $200 billion. Surveys done by large insurers and the Washington Business Group on Health place the cost of employee disabilities at 6-10% of payroll.

    Although some of the cost allocated to disabilities can be identified as workers' compensation, over half of the cost belongs under the heading of discretionary benefits. Sick pay, salary continuation, short-term Disability benefits--items that were previously considered insignificant or lumped into payroll costs--are becoming increasingly costly, and an increase of disability conditions due to aging of the working population and to new types of disabilities, means that companies must carefully examine the future of their disability programs.

    Companies are now beginning to consider outsourcing the management of these programs as a win for hard pressed human resource staffs and, very importantly, a win for the disabled employee who receives a high level of attention and guidance as enlightened plan administrators focus on abilities, coordination of effective treatment plans and recovery strategies.

    The process takes careful analysis and planning followed by consistent professional management. The financial results and especially the improved outcomes for disabled employees make the effort important to a company's continued success.

    Sedgwick provides the professional management necessary to ensure our client's disability benefit programs achieve their goals.
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    Question : What are the sources of disability benefit coverage?
     
    Answer :
    There are numerous forms of occupational and non-occupational Disability benefits offered to employees. Some coverages are mandated by Federal or State laws while others are optional benefit coverages sponsored by an employer. Whether mandated or discretionary, they are both affected differently by a wide variety of internal and external influences.

    Mandated Disability
    Benefit Coverages
    Typical Disability
    Benefit Coverages
    • state disability insurance (California, Hawaii, New Jersey, New York, Rhode Island, Puerto Rico)
    • Workers' compensation
    • Family Medical Leave (FMLA) / Federal & State
    • Federal social security
    • Sick pay
    • Salary continuation
    • Short-term disability (STD)
    • Long-term disability (LTD)
    • Disability life insurance benefits (AD&D)
    • Disability retirement


    Understanding and administering the confusing, fragmented, and overlapping discretionary and mandatory benefit plans described above is a challenge that few companies have mastered. The typical employer has a difficult, if not impossible, task of attempting to coordinate these programs to prevent duplication of benefit payments and unnecessary delays in the timely delivery of these benefits to employees.

    It is imperative that your disability vendor has the experience and expertise to assure you are maximizing your benefit resources and simplifying the process for your employees. Sedgwick is that vendor.
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    Question : What is integrated disability management?
     
    Answer :
    Integrated Disability Management is the integration of two or more disability benefit programs or the integration of disability benefit plans and workers' compensation coverage.
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    Question : What is self-insurance or self-funding?
     
    Answer :
    Self-insurance, or self-funding, is when the employer or plan sponsor assumes the financial risk for providing benefits (in this case Disability benefits) to its employees. In practical terms, self-insured employers pay for each claim as they are incurred instead of paying a fixed premium to an insurance carrier, which is known as a fully-insured plan. Stop loss coverage is often used to provide some protection to self-insured plans. A self-insured employer may set up a special trust fund to earmark money (corporate and employee contributions) to pay incurred claims.

    Short-term Disability benefits are ideal candidates for self-insurance. Costs are predictable and the individual claim, even one that hits the maximum plan coverage limit, is based on the employee's pay and lasts less than a year. In fact, many employers already have self-insured disability plans, but don't think of them as self-insured since they are funded through payroll. Sick pay and salary continuation plans are almost universally self-funded.

    Insurance is the payment of a premium to another party (insurer) in return for which the insurer agrees to pay for an event or events that represent the exposure to risk and costs that the first party seeks to avoid. The exposure to risk is usually classified as predictable versus unpredictable. Risk may also be further classified as catastrophic versus non-catastrophic. Self-insurance is simply accepting the limited risk exposure internally by setting aside internally developed funds.
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    Question : What is the importance of managing disability?
     
    Answer :
    Disabilities are on the rise. The aging population and the changes associated with new, more subjective types of disabilities result in employers seeing productivity dropping and the costs associated with short-term and long-term Disability benefits increasing.
    • Statistics show that 3 out of 10 working people will become disabled for 90 days or longer, between ages 35 and 65. Nearly 1 in 5 people will become disabled for 5 years or more prior to age 65.
    In light of these trends, effective disability management is critical for employers and their employees. Identifying and addressing the absence issues caused by these trends require a solid administrative foundation and appropriate care management services.
    • Is your Plan design being administered appropriately?
    • Do your Disability benefits work together to provide the income protection your employees need, while still encouraging them to return to work as soon as possible?
    • Do your employees feel it's easy to access their benefits and that your administrator's representatives know how to help?
    Sedgwick is the leader in administering self-insured Disability benefits. We can lower your costs and improve your employee relations by creating an efficient, employee-centered process that works within your culture. Our clients are so diverse and come from so many industries because we are able to adapt our processes to meet your business needs. Our only source of revenue is the service fees our clients pay us. Our success is your success.
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    Question : What should you expect from your plan administrator or TPA?
     
    Answer :
    The following checklist gives a preliminary idea of the range of services that employers should expect from potential disability plan administrators when they outsource sick pay, salary continuation, short-term disability and long-term disability plan management:
    • Consulting services on Plan design can help ensure the most effective Disability benefits program for the employer by filling in coverage gaps and applying offsets where overlapping voluntary and mandated benefits could otherwise result in double payments.
    • Paperless claims processing eliminates written forms for claimants, employers and attending physicians, removing administrative hassles for all parties and increasing productivity and processing time for initial benefit payment.
    • On-line access to the administrator's claims management system is another way to avoid pushing paper while facilitating access to claims data for inquiry or input.
    • Third party administrators can automatically withhold payments for employee deductions such as medical and dental plan contributions, eliminating the process of employee reimbursement of these fees and the accompanying administrative work.
    • Long-term disability pre-alert systems ensure a smooth transition from short-term disability to long-term disability by signaling the plan sponsor well in advance of the end of the long-term disability elimination period and facilitating coordination with other programs, such as disability pension benefits.
    • Electronic payment processing systems allow the administrator to send data electronically to the client's payroll department.
    • Disability payroll tax services enable the administrator to withhold and deposit the appropriate taxes for benefit plans with employer contributions.
    • Data analysis and reporting of program statistics, with the flexibility to customize reports to employers' needs, can help identify trends that could trigger proactive changes to disability programs.

    Undoubtedly, more and more services will be offered by disability plan administrators, as changing legislation and insurance options require new ways of handling plan administration, and as companies come to a clearer understanding of how outsourcing can benefit them. It seems inevitable, though, that as third party administrators' capabilities increase and corporations' resources decrease, outsourcing some or all disability benefit plan administration will become an even more attractive alternative.

    The important thing to remember for those employers in a position to consider outsourcing is that effective disability management is a process that takes time, commitment and patience. It involves changing attitudes, reexamining costs, rethinking work processes, and above all, looking for long-term success.

    If employers go into the process understanding this, outsourcing can be a big part of the solution to disability plan management problems.
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    Question : Who does Sedgwick serve?
     
    Answer :
    The absence and disability market segment we serve includes:
    • Large employers, who self-insure their Disability benefits for 3,000 lives and more.
    • Benefit consultants, typically hired by the employer to assist in evaluating their benefit programs and in selecting their vendors.
    • Claimants, or employees of our clients, applying for benefits.
    • Insurance brokers seeking benefit administration services for their clients.
    • Strategic partners / Vendors working with Sedgwick to add value throughout the supply chain.
    • Members of the press tracking industry or public policy issues.
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    Question : Why health and disability?
     
    Answer :
    Disabilities are medical and life events that have inexplicably been viewed as independent. Creating a program that integrates components of group Health & disability benefits provides opportunities for:
    • Earlier recognition of disease states.
    • Improved customer satisfaction.
    • Identification of non-medical issues impacting return to work.
    • Lowering risk levels for chronic disease patients.
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    Question : Why is self-funding short-term disability important to large employers?
     
    Answer :
    Our own statistics show that on average 7 1/2 % of our client's workforce will be out on short-term disability (STD) at any given time. With that in mind, self-funding STD is a sensible decision for large employers due to finite duration and predictability of risk. In the majority of cases, self-funding will be less expensive than insurance and provide much more flexibility.

    All attempts to manage disability must begin as early as possible, and the application for STD benefits generally starts the process. Sedgwick organizes the administration of all absence and disability benefit plans with particular emphasis on process efficiency and outcomes management.

    Sedgwick excels at both the clinical management and the adjudication process to ensure accurate and timely decisions, and also exceeds expectations in our ability to exchange data with our clients and vendor partners.

    Payroll feeds to multiple pay centers, eligibility feeds, data transfers from and to health care vendors, and workers' compensation administrators -- all of the day-to-day activity essential to achieving world class benefit administration.
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    Question : Why is sick leave one of the most difficult absences to manage?
     
    Answer :
    Casual absences can be the most difficult absences to manage, particularly for saaried employees.

    The reporting and administration are typically handled locally by a supervisor, creating significant variety in the style and effectiveness of management.

    Although paid sick leave is not required by law, most large employers offer at least five days of paid time off each year for sick or personal absences.

    Sick leave or paid time off usually occur prior to, or during, the elimination period for short-term disability.

    Coordinating sick leave and STD when an employee is out of work, and knowing when to initiate FMLA notification can be tricky if your supervisory staff is not well versed on their responsibilities and the law.

    Sedgwick offers seamless administration of your sick leave/paid time off plans with FMLA and your short-term disability plans, including state disability.

    Our processes will ensure consistent application of plan rules and coordination of all the sources of income benefits.
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    Question : Why self-fund a disability plan?
     
    Answer :
    According to the Duncanson & Holt Group, self-funding benefits employers in many ways:
    • Control of Plan design;
    • Administration tailored to the employer's needs;
    • Cash flow benefits;
    • Return on investment for reserves;
    • Cost & utilization controls;
    • Effective claim processing;
    • Lower Cost of Operation;
    • Elimination of most premium tax;
    • Carrier profit margin & risk charge eliminated;
    • Mandatory benefits avoided (State mandates can be avoided as self-funded programs are governed by ERISA); and
    • Risk management effectiveness.
    According to Sedgwick's client base, the major reasons are:
    • Employer control; and
    • Cash flow.
    EMPLOYER CONTROL:

    Employers develop sick leave, salary continuation plans based on philosophy and competitive conditions. Often, these plans reflect the company's culture. The plans can be modified to meet changing conditions. The mandated state disability Plans do not work in conjunction with the employer's plans, rather it is the employer who must tailor the company paid absence programs to fit around the State system. The intrusion of the State into the paid absence equation means that the employer loses control of benefit qualification (it is hard to deny a sick leave claim while the person is receiving State SDI). Also, the employees are faced with numerous sources, forms and requirements to obtain benefits. Administrative delays in the world of short-term disability, always mean unnecessarily longer claim duration.

    CASH FLOW:

    Insured programs, due to the very central issue of risk transfer, require that the insurer set aside a portion of the premium dollar (reserves) to pay for claims that would continue after the termination of the insurance contract. This is not so with self-insurance, since costs are part of an ongoing program and become part of the expense stream. In addition to reserves, insurers must factor in premium taxes, profit, sales expenses, and overhead costs. Self-funding and using a Third Party Administrator such as Sedgwick, can lower non-benefit costs dramatically. Do you know why Self-Insuring state disability is so Important?
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    Question : Why self-fund long-term disability?
     
    Answer :
    Although a small percentage of disability claims qualify for long-term disability, they are usually the most severe and have the largest impact on an employer's bottom line.

    Sedgwick offers expert advice and administrative solutions for self-funded long-term disability plans. Self-funding LTD provides much more flexibility in design, improves cash flow, and can produce significant savings over an insured LTD policy.

    Your corporate profile and tolerance for risk are key to determining whether your company is a good candidate for self-funding LTD. Sedgwick will guide you through the analysis, enrollment, implementation, and ongoing administration of your LTD plan. We can provide alternative risk arrangements and plan document preparation and review to ensure your plan achieves your goals.
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    Question : Why should salary continuation be handled by a third party administrator?
     
    Answer :
    Salary continuation is often the most expensive income replacement plan offered by an employer because it is usually an unmanaged 100% income replacement benefit. Decisions are made on a decentralized basis by the employee's supervisor. If your company provides salary continuation benefits, the need for an unbiased third party administrator becomes paramount.

    Often the duration of salary continuation is based entirely on the duration of the underlying benefit plan, i.e., sick leave, state disability, or short-term disability. If those plans aren't closely monitored, the potential for excessive duration and/or overlapping payments is high.

    Sedgwick is one of the few companies that has the ability to manage all of your income replacement plans, including sick leave and salary continuation programs. Sedgwick offers seamless administration of your salary continuation plan with all of your disability benefit plans. Our Plan design expertise can assist you in creating the best program for your employees while assuring each claimant of an objective and fair benefit application process.
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    Question : What is California Paid Family Leave (PFL)?
     
    Answer :
    California Paid Family Leave (PFL) is provided to California workers through the State Disability Insurance (SDI) and is paid to workers who suffer a wage loss when they take time off work to care for a seriously ill child, spouse, parent or domestic partner, or to bond with a new child due to birth, adoption, or foster care placement.
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    Question : How does California Paid Family Leave (PFL) differ from disability benefits provided to California employees?
     
    Answer :
    The disability program compensates workers who suffer a wage loss when they cannot work because of their own illness or injury. Paid Family Leave (PFL) is a component of SDI insurance that provides wage replacement benefits to workers for a family member's illness or injury or to bond with a new child.
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    Question : When will California Paid Family Leave (PFL) payments begin?
     
    Answer :
    Benefits will be payable for PFL claims commencing on or after July 1, 2004.
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    Question : What is the California PFL benefit?
     
    Answer :
    The PFL benefit is the same benefit that the employee would be entitled to for disability benefits under the SDI program: The benefits provided under the State program are 55% of base period wages up to a weekly maximum benefit amount. Please refer to the state’s website at http://edd.ca.gov/ for current weekly minimum and maximum benefit amounts. If you are covered by your employer's California Voluntary Plan, rather than by the state program, the benefits for PFL will be equal to or greater than those provided under the state program. Your employer's benefits booklets or Plan Document will outline these benefits.
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    Question : Who is eligible for California Paid FamilyLeave?
     
    Answer :
    Employees covered by a California Voluntary Plan (CVP), and employees who are covered by California State Disability Insurance (SDI) will also be covered for California PFL.
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    Question : Is California PFL employee or employer paid?
     
    Answer :
    Your cost for PFL is included in your contributions for the Voluntary Plan or SDI, depending on what program you are covered in. In most cases, the contributions are employee paid, but under a Voluntary Plan they may also be paid by the employer. If the employer pays for the program, or part of the program, benefit taxability issues may arise if the employer elects to pay PFL contributions. Information on the cost of the program can be obtained from your employer.
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    Question : Are California PFL payroll deductions mandatory?
     
    Answer :
    Yes. Beginning January 1, 2004, employers are required to deduct the PFL contributions from the wages of employees who are covered by the SDI program, unless the contributions are paid by the employer.
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    Question : When do California PFL contributions begin?
     
    Answer :
    Contributions began on January 1, 2004
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    Question : What is the contribution rate for California PFL?
     
    Answer :
    The contribution rate for PFL is part of the SDI rate. For information regarding the current SDI contribution rate and taxable wage limit, please refer to the state’s website at http://edd.ca.gov/ .
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    Question : How many weeks can an individual collect California PFL?
     
    Answer :
    An individual may receive up to 6 weeks of benefits in a 12-month period, unless stated otherwise in the employer’s plan document.
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    Question : Will there be a waiting period for California PFL?
     
    Answer :
    Yes. PFL requires a 7-calendar day non-payable waiting period, unless otherwise stated in the employer’s plan document.
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    Question : Can my employer require me to use accrued, but unused vacation?
     
    Answer :
    Yes. The law gives an employer the option to require an employee to take up to two weeks of earned but unused vacation leave. However, this option does not relieve them of any collective-bargaining duties they may have with respect to vacation leave. If an employer's policy requires the use of vacation, one week of the employee's vacation pay can be applied to the PFL waiting period and the second week of the employee's vacation pay would result in a delay in benefits. The employee would begin receiving his/her PFL benefits in the third week. The vacation policy will be communicated to you by your employer.
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    Question : How do I file a leave request?
     
    Answer :
    You will be able to file your leave request online or with a customer service representative. If your employer does not require you to file your leave request directly with them (very few do), then you may file with Sedgwick using the procedures described below:
    To file your leave request online: Use our self-service online claim form on our website. Once your leave request is entered into our system, you will receive an email with your Sedgwick claim number.

    To file your leave request by telephone: Call Sedgwick at the toll-free phone number listed on your benefits card. If you do not have your benefits card, you can call us on our main claims line at (818)591-2772. A customer service representative will take your leave request information over the phone, and provide you with additional information. Be sure to note the Sedgwick claim number provided to you.

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    Question : What documentation will be required for a bonding leave request?
     
    Answer :
    PFL leaves for bonding will require supporting documentation such as a birth certificate, completed hospital or birthing center documents, or Department of Social Services forms for adoption or placement.
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    Question : How does the leave process work?
     
    Answer :
    You should first file your leave request with Sedgwick. Once you have filed your leave request, Sedgwick will contact your employer and obtain the employment information (your date of hire, employee status, etc.) that we will need to begin processing your leave.
    After Sedgwick has received the necessary information from you, your employer, and the physician (if applicable) your leave request will be assigned to an Examiner for review.
    If you have requested a Short Term Disability (STD) leave for your own Serious Health Condition (SHC) or a Paid Family Leave (PFL) to care for someone else with a SHC, a determination resulting in an approval, denial, or request for additional information will be made within approximately 4 business days.
    If your leave request is approved, you will receive your payment from either Sedgwick or your employer, depending on the payment schedule your employer has established with Sedgwick.
    If your claim is denied, you will be notified in writing. If Sedgwick needs additional information, you will be contacted by telephone or letter, depending on the information needed. If you are not returning to work on your scheduled return to work date, the physician (if applicable), may call Sedgwick to report the extension, or you can download the appropriate Supplemental Certification Form .
    If you download this form, fill out the top portion and have the physician complete the bottom section of the form, and either fax or mail it to Sedgwick.
    Once Sedgwick has received your extension, we will review the extension and a determination resulting in an approval, denial, or request for additional information will be made within approximately 4 business days.
    If you miss a payment and your claim is subsequently approved or extended, your current benefit amount will be combined with any benefits you were due from the prior period and paid to you in your next payment.
    Sedgwick makes every effort to approve and pay claims in a timely manner to avoid any disruption to the claimant. However, there are times when we are unable to approve and pay a claim on the scheduled payment period as determined by your employer. This could be caused by a delay in filing the claim, receipt of medical documentation or other required information. If this should happen, any amount owed will be paid on the next scheduled payment date.
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    Question : How does Sedgwick get the physician's information for my leave request?
     
    Answer :
    If you are filing a new leave request and we have not received information from the physician for this leave, inform the physician to call Sedgwick immediately. The physician will need to supply Sedgwick with information regarding the Serious Health Condition (SHC). If the physician is unable to call, you can download the applicable Certification form for the physician to fill out. Fill out the top portion of the form and instruct the physician to fill in the remainder of this form and fax it to Sedgwick as soon as possible, to complete the filing process. If you are not returning to work on your scheduled return to work date, download the appropriate Supplemental Certification Form and fill out the top portion. Have the physician complete the form and either fax or mail it to Sedgwick in order to continue your benefit payments. Please Note: Filing does not guarantee you will receive benefits. You must first meet the criteria and provisions of your company's plan. For a copy of the plan document, please contact your benefits department.
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    Question : Can Sedgwick contact the physician to get the necessary information to process my leave request?
     
    Answer :
    If you are experiencing difficulty having the physician provide information to Sedgwick, please contact us with the physician's fax number and we can fax a form to their office in an attempt to obtain the required objective medical information. If your employer has established procedures with Sedgwick to call the physician upon initial filing, we will phone the physician for you.
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    Question : What happens if Sedgwick cannot get information from the physician?
     
    Answer :
    If you have requested assistance in obtaining medical information from the physician, Sedgwick will assist you. However, if we are unable to obtain the necessary medical information from the physician, it is ultimately your responsibility. If Sedgwick does not receive objective medical information to support your leave request, your leave cannot be approved.
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    Question : How do I know if Sedgwick received the fax I sent?
     
    Answer :
    Sedgwick logs in all faxes received and they can be found in the Document Delivery screen.
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    Question : What should I do if the physician releases me to return to work earlier than my original expected return to work date?
     
    Answer :
    Contact Sedgwick immediately, and inform us of your early return to work date. When you report to work present the signed release form to your Supervisor or HR representative.
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    Question : Kaiser is the medical provider. What do I need to do differently?
     
    Answer :
    Kaiser needs a signed Medical Release from you or the patient before they will provide Sedgwick with medical certification for your leave request. There are three options for providing this to Kaiser: 1. A hand-written note with your signature or the patient's signature and date authorizing them to release information to Sedgwick 2. The Kaiser Release of Information form given to you or the patient by Kaiser at each visit The Sedgwick Release of Information Form, which you will receive from Sedgwick after filing your leave request (or one can be downloaded directly from our website). Be sure to take this important step of providing Kaiser with a release as soon as possible, as the Kaiser Disability Office will not release information without one of these forms. (Most Kaiser locations will accept a fax.) To assist the Kaiser Disability Department in providing medical certification, you may also provide them with a Certification Form for Initial Certification of Disability (Physician's Certificate) at the time you provide them with the medical release form. You may also ask them to phone in the certification by having them call the toll-free 800 number for Sedgwick (this method is the quickest way to expedite your claim). If they will not call Sedgwick, follow the steps listed above. Continue to follow up with the Kaiser location until you are assured that the forms have been completed and sent to Sedgwick. You can check the status of your leave request by going to our Claimant Home Page, and clicking "Check the Status of Leave". Just follow the easy instructions for registering to see all details of the status of your forms and leave information. If you are planning a future leave request (e.g. pregnancy, surgery, bonding), you can expedite your leave request by downloading and printing the Physician's Certificate and Release of Information forms ahead of time and taking them to the Kaiser Disability Office. Kaiser's website is: www.kaiserpermanente.org
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    Question : What should I do if the physician determines that I will not be able to return to work on the date provided on the first certification provided by the physician?
     
    Answer :
    Please do the following if the physician determines that you are unable to return to work on the date they provided on the first certification: Ask the physician's office if they will call Sedgwick as soon as possible, to report the new return to work date and provide verification of need for an extension. Or have the physician complete the appropriate Supplemental Certification Form. Fill out the top portion of the form and instruct the physician to fill in the remainder of this form and fax it to Sedgwick as soon as possible. Once Sedgwick has received your extension, we will review the extension and a determination resulting in an approval, denial, or request for additional information will be made within approximately 4 business days. To avoid a delay in payment of your benefits we suggest you request an extension as soon as you are aware one will be needed.
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    Question : How long will it take to process my extension request for my leave?
     
    Answer :
    It is Sedgwick's goal to process an extension of a leave request within 4 business days from the time the completed extension is received. You can check the status of your existing leave by accessing the Check Leave Status page. Occasionally there is a need for additional medical records. If additional medical records are required to make a decision regarding your request for extension, the physician's office will be contacted within 4 business days.
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    Question : Why didn't Sedgwick approve my leave to the date the physician requested?
     
    Answer :
    Sedgwick reviews the information provided by the physician and determines if there is medical evidence to support your leave request. If the physician has indicated you will be away from work beyond normal guidelines for the Serious Health Condition (SHC), Sedgwick will approve your leave to a certain date, and re-review your leave request when that date arrives (to see if the additional time is supported).
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    Question : What do I have to do during my leave?
     
    Answer :
    You have a very important role in the process. To ensure you receive the leave time that you are entitled to, you must:
  • Sign and return all forms to Sedgwick as soon as possible
  • Stay in touch with Sedgwick and your Supervisor; provide information as requested
  • Return to work when your leave ends
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    Question : Why would Sedgwick need to request a copy of the medical records?
     
    Answer :
    If the information presented by the physician does not completely support the leave request, Sedgwick may request a copy of the medical records in an attempt to obtain objective medical information.
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    Question : How long will it take to process my California Paid Family Leave (PFL) request?
     
    Answer :
    Review of your leave request will be performed in approximately 4 business days from the time we receive all necessary information. You can help speed up the process by doing the following: Sign and return to Sedgwick all forms as quickly as possible Ensure the physician immediately provides Sedgwick with the medical information requested Stay in touch with Sedgwick throughout your leave
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    Question : How much can I expect to receive for California PFL benefits?
     
    Answer :
    The actual amount of your PFL payment is determined by several factors:
  • The percentage of replacement income your plan specifies (this will most likely be the same as the state program of 55%; or it may be based on length of service, or other requirements in the plan)
  • Income received from other sources could be deducted from your gross benefit amount
  • Your employer may have made arrangements for Sedgwick to pay your health insurance, 401K, etc. while you are disabled, (this would be deducted from your payment)
  • Taxes could be withheld if you are covered under a taxable plan.
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    Question : When will I actually receive my PFL benefits?
     
    Answer :
    Sedgwick wants you to receive the benefits for which you may be eligible as quickly as possible. Review of your claim will be performed in approximately 4 business days from the time we receive all necessary information. Sedgwick will make every effort to obtain the required objective medical information from the physician. You can help speed up the process by doing the following: Sign and return to Sedgwick all forms as quickly as possible. Ensure the physician immediately provided Sedgwick with the medical information requested Stay in touch with Sedgwick throughout your leave. If your leave request is approved, you will receive your payment from either Sedgwick or your employer, depending on the payment schedule your employer has established with Sedgwick.
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    Question : When will California PFL benefits end?
     
    Answer :
    PFL payments could end due to any of the following situations:
  • The care recipient no longer requires care
  • The employee has reached the maximum benefit amount or time allowed under the Plan (see your benefits booklet or Summary Plan Description to find out the applicable provision)
  • The employee has returned to work
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    Question : Will deductions be taken from a benefit payment?
     
    Answer :
    Depending on the plan under which the employee is covered, some of the deductions that could be taken from benefit payments include:
  • Taxes
  • Health Insurance
  • Other Income/Benefits
  • 401K
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    Question : May an employer require employees to take all 6 weeks of California PFL at once?
     
    Answer :
    No. The employee may take the benefits intermittently or in blocks of time over the 12-month period.
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    Question : Does California PFL offer job protection?
     
    Answer :
    PFL is a wage replacement program that does not offer job protection. However, some individuals may be eligible for job protection under other laws, such as the Family Medical Leave Act (FMLA) or California Family Rights Act (CFRA).
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    Question : If an employer does not require their employees to use vacation, can the employee still use their vacation?
     
    Answer :
    Yes. If the employer's policy does not require the employee to use vacation, the vacation pay does not conflict with the receipt of PFL. The employee can apply one week of vacation pay to the PFL waiting period and any other vacation pay received after the waiting period would be in addition to PFL benefits.
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    Question : How are California PFL benefits affected if the employee receives sick leave benefits and PFL at the same time?
     
    Answer :
    Consistent with the California SDI program, sick leave wages are treated as wages. The PFL benefits will be reduced by the amount of sick leave wages received, and may render the individual ineligible for benefits depending on the amount of sick leave wages received and the individual's weekly benefit amount.
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    Question : Are California Paid Family Leave (PFL) benefits taxable?
     
    Answer :
    California Paid Family Leave benefits are subject to withholding of Federal income taxes. They will not be subject to withholding of FICA taxes (Social Security and Medicare) or California state income taxes. If Sedgwick pays your Paid Family Leave benefits, a form W-2 will be issued for these payments and will be sent by January 31st following the end of the taxable year.
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    Question : How does Sedgwick obtain my tax status?
     
    Answer :
    If Sedgwick is providing you your benefit payments (versus your employer making the payment), we will attempt to obtain your W4 information directly from your employer prior to your first payment. If we do not receive the W4 information at the time your PFL claim is approved, your payment will default to a status of single with zero allowances in order to expedite the payment of your claim. If you wish to provide Sedgwick with your current or updated W4 information please fax to Sedgwick a signed form W4 (and be sure to include your claim number). Our fax number is 818-591-7664. You can download the current W4 form by clicking on the following link: http://www.irs.gov/
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    Question : What if my employer pays my PFL benefits rather than Sedgwick?
     
    Answer :
    If your employer pays your PFL benefits, then your employer will be responsible for withholding and reporting taxes from your PFL benefits. Your employer will also issue a form W2 reflecting your PFL benefits.
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    Question : Why could my benefit payment be late?
     
    Answer :
    Sedgwick has not yet received information supporting your leave request Information received by Sedgwick is incomplete and/or Sedgwick needs additional information on your leave request The necessary information was received after the normal payroll cycle had run A waiting period may apply to your leave request Please note: If you miss a payment and your leave request is subsequently approved, your current benefit amount will be combined with any benefits you were due from the prior period and paid to you in your next payment.
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    Question : Why haven't I been paid from the first date of my leave request?
     
    Answer :
    Some plans have a waiting period that must be satisfied before benefits are payable. In order to find out if your plan has a waiting period and what that waiting period consists of, please refer to your benefits booklet or summary plan description.
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