Several clients have asked questions related to COVID-19 and their group disability insurance. Here’s a compilation of how carriers are administering claims.
Question: Is someone automatically disabled if he/she is placed under a quarantine related to the Coronavirus?
Answer: No. Standard policy language requires that an insured be disabled from his/her own occupation. Therefore, an insured is not automatically considered disabled if under a quarantine for any reason. However, some policies may contain quarantine provisions. It is important that you check your policy or (if self-insured) plan document, as this will dictate how claims are administered.
Question: Will a disability claim for an insured who is under a quarantine related to the Coronavirus be approved?
Answer: Possibly. Every claim is reviewed based on the disability policy language and the unique facts of the insured’s situation, including factors such as the diagnosis and medical certification; the progress of the virus/condition; the specific quarantine that the insured is subject to; and the insured’s ability to work remotely, among others.
Claims submitted listing a diagnosis of Coronavirus will be processed in compliance with all applicable contract provisions. In general, to be eligible to receive benefits, an insured must provide proof that he/she is:
- Under the care of a Health Care Provider who is certifying the insured’s disability; AND
- Unable to perform his/her occupation in the workplace or at home via remote access.
If the employee is symptomatic, then he/she may have a qualifying condition under FMLA (or even the ADA) which would require him/her to take leave. An important consideration is that the employee must be quarantined and not able to return to work. To the extent the quarantine is optional and the employee is symptomatic, the employee may also qualify for FMLA.
Situations involving furloughs or layoffs may be more complex. This may include eligibility for coverage for those who were actively at work prior to a furlough or layoff on a prior carrier’s policy. How will pre-existing conditions be administered? What about employees whose hours are reduced below the minimum hours required in the policy definition for eligibility? – There are many scenarios that may need to be reviewed by a broker with in-depth knowledge of contract language and claims experience.
Employee Benefit Advisors provides employee benefits, tax-advantaged healthcare, compliance guidance for ACA and Health & Welfare DOL Audits, and PEO Advisory & Consulting Services.
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