Claim Decisions
CIGNA Disability Management Solutions' Claim Philosophy is to:
- Pay all covered claims and fulfill our contractual and fiduciary responsibilities.
- Treat our customers and claimants as we would want to be treated.
- Act with integrity, objectivity and a sense of urgency in the evaluation of claims.
- Assist our employer customers and their disabled employees in the shared goal of returning to productive work.
This section addresses the specifics of each type of claim decision and the manager's role and responsibilities within each one.
Pending the Claim
The period of time during which a claim is being reviewed and investigated before a determination is made is called the "Claim Pending" stage. During this stage there is nothing for you as the manager to do except to continue weekly "check-ins" with the employee. See Ongoing Absence for details.
In the case of short-term disability, claims decisions are made 50% of the time within five business days of receipt of the claim and over 80% of the time within ten business days of receipt of the claim.
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Claim Approved
There are two types of claim approvals:
- Approval — Awaiting Additional Medical Information
In this case the disability claim has been approved, but no firm return-to-work (RTW) date or length of disability has been established yet. In many cases the approval letter has an "approved through" date, which is the duration for which the disability has been approved, and is usually based on the employee's medical treatment (i.e., date of the employee's next doctor visit). The "approved through" date does not necessarily mean the employee will return to work on that date. If the disability is continued at the time of the next medical appointment, another approval letter will be sent updating the next "approved through" date.
- The claim manager will send an approval letter to the employee with the "approved through" date.
- You should continue communication with the employee and discuss potential RTW options.
- If you have any questions (i.e., change of approved-through dates) or status requests you can call or email the claim manager.
- Approved with a Return-to-Work Date
In this instance the claim manager will contact the employee and you to notify you of the expected RTW date. See RTW section for details.
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Claim Denied
A claim may be denied if the employee is not eligible; does not meet the definition of disability in your employer's benefits contract; if the condition s/he has is not covered by the disability benefit contract; or if the medical information supports a determination that the employee is able to work. This list is not all-inclusive - other exclusions may apply depending on your benefit plan
If the employee's claim is denied, the employer will be informed of the decision by the claim manager. If your employee has been notified that his/her request for disability benefits was denied by CIGNA Disability Management Solutions, s/he now has 180 days to appeal this denial. This amount of time for appeal is required by federal regulations (if the plan is covered under ERISA).
At this point the employee may decide to return to work (see RTW section). If the employee does not return to work, as the manager, you now have several responsibilities related to the employee's eligibility for Family Medical Leave (FML) that should not wait until an STD appeal is filed or an appeal decision is made. A claim that has been denied may still be eligible for Family Medical Leave (see FMLA section).
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Decision Pending
In this instance the employee's pay is stopped, but a claim decision is not yet made.
- Federal regulations allow the employee 45 days to submit information on their claim
- Unless a claim manager receives information that allows them to approve or deny a claim for benefits, they must wait at least 45 days before making a claim decision. We may avail ourselves of one or both of the 30-day extensions to allow us to gather more information
- If you hear from the employee regarding this issue refer him or her to the claim manager
- If the employee wishes to return to work and you have not been notified by the claim manager or the healthcare provider, contact the claim manager with this information and ask about the status of the claim decision
- You should not make any plans for the employee's return to work (RTW) or other RTW decisions until a claim decision has been communicated by the claim manager
- You should not allow the employee to return to work while the claim is pending without a release from the provider or notification from the claim manager
- If you have any questions, please contact the claim manager
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