<Organization Name> / Section ______
Policy # ______
Date ______
Revision date______
Page 1 of 7

SAMPLE Policy and Procedure

Short-Term & Long-Term Disability

OBJECTIVE: / To provide guidelines for the immediate care of <Organization’s Name> employees in regards to injury or illness and to coordinate the short-term and long-term disability programs in order to provide pay for employees who are unable to work due to injury and illness without duplication of benefits.
SCOPE: / <Organization’s Name> employees
POLICY: / <Organization’s Name> will provide short-term and long-term disability benefits to eligible employees, as set forth in this policy. <Organization’s Name> provides benefits according to the short-term and long-term disability contracts of their carrier so those employees are insured against loss of earnings as a result of illness or injury. Long-term and short-term disability programs are administered in accordance with the United States Employee Retirement Income Security Act.
Employees eligible to receive paid time off will have the option of complementing any compensation following a job-related disability up to 100% of their bid number of hours.
DEFINITIONS: / Disability Claim Form- the form utilized to document injury or illness. The employee is to complete their portion of the form and then have their treating physician/medical provider thoroughly respond to the physician statement portion of the form.


  1. An injured or ill employee shall provide 30 days advance notice of the need for a leave of absence when the need is foreseeable or as soon as practical when the leave is not foreseeable (within two business days).
  1. When an employee is injured or ill they may collect disability benefits. In order to do so the application for benefits must be completed. This form may be obtained in the Insurance Department.
  1. The employee shall be responsible to complete their portion of the form and then obtaining their treating physician/medical provider’s statement. Failing to provide the requested information may cause a delay in benefits or benefits may not be authorized.
  1. The employee will be permitted to have 15 calendar days to obtain medical certification to comply with the rights under the Family Medical Leave Act. The Family Medical Leave form may be obtained from Human Resources.
  1. The employee has the option to decline the release of specific medical information to <Organization’s Name>, however information regarding work status and physical limitations will be available to <Organization’s Name>. This information is made available for the purpose of returning the employee to work in some capacity.
  1. The supervisor will notify the Human Resources when an employee calls in absent for any reason. Notification will occur on a daily basis by 10 a.m. and include call-ins for the previous 24 hours. Notification may be accomplished in person, by leaving a voice mail message or sending an email message.
  1. The employee will be notified Human Resources within two business days that the employee’s absence is being counted as Family Medical Leave.
  1. An employee who falsifies information will be subject to corrective

action, up to and including, discharge.


  1. An employee who makes a claim for disability benefits may be required to present for an independent medical evaluation. A refusal may cause the employee to not be eligible for benefits.


  1. Employees may treat with physicians/medical providers of their choice according to coverage outlined in their plan documents
  1. Employees reporting an injury or illness may have their claim reviewed by the insurance carriers claim payer, nurses or physicians.
  1. <Organization’s Name> may require employees to obtain a second medical certification from a health care provider. <Organization’s Name> will choose a health care provider for the second opinion who they do not regularly contract with or otherwise regularly use the services of. If the employee’s and <Organization’s Name>’s designated health care provider’s opinion differs, the employee may be required to be evaluated by a third health care provider at no expense to the employee. This third opinion shall be final and binding. The third health care provider will be approved jointly by the employee and <Organization’s Name>. The “Certification Health Care Provider” form will be used to obtain the certifications.
  1. Following your physician/medical provider’s evaluation the employee will need to provide documentation of work status. The employee should present this information to the Insurance Director who will be responsible to review the information with the Transitional Work/Risk Management Coordinator for possible return to work.


1. Employees are encouraged to return to work following illness or injury as long as they are medically able. Employees shall be required to obtain written notification from the physician or medical provider of their ability to work, and specific physical limitation, if any. Return to work shall be authorized by the Return to Work Coordinator/Risk Manager.

2. Employees, who may work with limitations, shall return to work according the Temporary Transitional Work Program Policy.


1. The Insurance Director is responsible for collecting documentation of disability for non-occupational conditions. Documentation will then be forwarded to the insurance carrier.


  1. An eligible employee will receive payment from insurance carrier benefits beginning with the employee’s eighth consecutive calendar day away from work due to a disability; this is called the elimination period.
  1. In order to be eligible to receive disability benefits the employee’s normal hours worked in their regular position must be 32 hours or more per pay period.
  1. Employees who are released to return to work with physical limitations may choose to take unpaid Family Medical Leave. If they do so and a task is available within their physical limitations, then their disability benefits may be in jeopardy.
  1. As provided by the short-term disability contract payments will be made at the rate of approximately 66 2/3% of the employee’s budgeted weekly wage, but not more than the maximum weekly rate of $600 for 13 weeks. The budgeted weekly wage does not include overtime or shift differentials.
  1. If the employee’s condition continues past 90 days then they may be eligible for long-term disability benefits. Eligible long-term disability employees may receive 40% of the employee’s budgeted monthly wage, up to $1000 per month. If purchased in advance, the employee may be entitled to a higher benefit rate, which is 60%, up to $3,000 per month. Again these benefits are calculated based on the budgeted wage. The budgeted wage does not include overtime or shift differentials.
  1. If the employee is not totally disabled, you may still be eligible for benefits, however this cannot exceed more than 80% of the employee’s pay.
  1. While an employee is off work due to an injury or illness, the employee may elect to complement his/her income with accrued paid time off. Paid time off shall replace the employee’s normal hours worked. The request to use paid time off to complement benefits may be made by contacting Human Resources.

(a)Employees who use paid time off to supplement disability benefits shall have an equal amount of pay deducted from their paid time off banks.

(b)Where complimenting disability benefits with paid time off results in a duplication of benefits, the employee will be required to reimburse <Organization’s Name>. Failure to repay this amount will be subject to corrective action, up to and including discharge.

(c)There will be no duplication of payment for disability or paid time off such that an employee would receive more than 100 percent of pay.

  1. Family Medical Leave shall run concurrently with all eligible disabilities that cause qualifying employees to miss work.
  1. If an employee is totally disabled from work, due to an injury or illness, benefits shall be continued for 12weeks. If the employee wishes their coverage to be continued thereafter, they may elect to pay for certain benefits under COBRA to <Organization’s Name>.
  1. <Organization’s Name>’s short-term and long-term disability insurance carrier determines the appropriateness and duration of an employee’s claim for disability benefits. Each claim shall be reviewed and analyzed.
  1. Medical information will be maintained in a confidential manner.
  1. As provided by law, an employee may disagree with any decision made by the insurance carrier, by filing an appeal through the insurance carrier. The <Organization’s Name> short-term and long-term disability plan is administrated according to the Employee Retirement Income Security Act of 1974 which entitles participants in the plan certain rights and protections.
  1. When an employee is absent from work for at least three days, the employee should be given a copy of the pamphlet that summarizes their disability benefits and the Temporary Transitional Work Program by Human Resources. This pamphlet also includes other applicable information.
  1. If the employee qualifies for Family Medical Leave the employee’s job will not be posted or filled until the employee has exhausted a total of twelve weeks on a rolling calendar year which is in accordance with the Family Medical Leave Act.


  1. The Insurance Director will be responsible for assessing, monitoring progress, and processing all disability claims to the insurance carrier.
  1. The Return-to-Work Steering Committee will conduct periodic meetings, which will review the disability management process. This committee will be comprised of a management representative from Risk Management, Nursing, Finance, Human Resources, Operations, and Safety.
  1. Short-term or long-term disability insurance carrier may conduct a review of all open claims.


RESPONSIBILITY:The Director of Human Resources is responsible for the administration of this policy.

This document contains representative examples only to provide you with guidance. Please consult with your Risk Control consultant/professional with respect to the use or development of your own safety management tools.