how does the CA SDI decide if a claim involving COPD is legit? Are there objective guidelines?
State/Country relating to question: California
Hello and welcome,There are specific guidelines for SDI eligibility, including:
If a spouse, registered domestic partner, parent, or child is providing care for the claimant, he/she may be eligible for Paid Family Leave benefits.
An independent medical examination to determine your initial or continuing eligibility may be required.
If you are found to be ineligible for all or part of a period claimed, you will be notified of the ineligible period and the reason.
Here is a link that provides this criteria and more information on this issue:
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Tina, thanks for your quick reply. I think a little more context regarding my situation will help. I am scheduled for an Appeal Hearing before a California Administrative Law Judge to appeal the "Deniual of Benefits" I recieved from my Voluntary CA SDI. They have told me over the phone that they cannot approve any more payments (on SDI since 4/1/2012) because their medical department does not approve of my treatment plan (not enough doctor's visits). I have notes from my doctor indicating that my disability is permanant. Do you have any thoughts to help me through this Appeal hearing? Thank you for your time...tom
Hello again, Tom.Has the commission indicated what would constitute enough visits in their opinion, so that you could be awarded benefits?Have you applied for disability benefits through the SSA? If not, why?
Tina, my Vol SDI carrier (CIGNA/SEDGWICK) has not indicated what they think are 'enough' visits. To me it seems like they are just stalling. When I filed my appeal (6/30/2012) they got better for about a month, then asked me to withdraw my appeal. I didn't :) They have been extremely difficult to work with, they immediaitely paid me for the period in question when they found I had filed an appeal, but are now telling me they cannot contimue payments. They always seem to have some problem with my claim, they need more information, they need medical notes, when they get them, they can't read them..
I have applied for SSA `6/15, and have recieved notice my benefits will be paid startin from Sept 2012 (paid in mid October). They need to know how much SDI is paying so they can co-ordinate benefits. What a mess...
I'm sorry Tom but I am confused now. Are you appeal a denial of coverage by a private carrier or the CA SDI program denied your application for benefits? I was under the impression it was SDI that you were appealing. That's not the case?
Sorry for the confusion Tina. In California, there is mandatory SDI coverage which is paid for by employee payroll deductions. You can use the regular state run SDI, or you can chose a "Voluntary SDI" plan that is approved by the state. The voluntary plan must be equivalent to the state plan in all aspects, but must be better than the state plan in at least one aspect. I am in a Voluntary SDI plan which is administerred by CIGNA. When there is a denial of benefits, the appeal takes place through the appeal process already in place for the state run plan. I have been denied continued benefits from my voluntary plan. I hope this makes it more clear..
I see. Thank you so much for clarifying that, Tom. Now it makes sense to me.If you meet the eligibility requirements I previously set out, I would expect you to prevail in this case. This appears to me to involve a bad faith refusal to pay by this private insurer.If you are otherwise eligible, this reason for denying coverage, that there are not enough visits, sounds very suspect to me.In any appeal of this type, it is best to retain a local attorney to represent you at the appeal, to best protect your legal rights. I would expect an experienced attorney could make it clear that the insurer is not acting in good faith and the denial of your claim must be reversed.Here is a link that provides information on what constitutes a bad faith claim against an insurer. I would suggest the insurer in this case may have crossed the line. If you are unable to work, as indicated by your doctor, and meet the other eligibility requirements, I would expect the case to be reversed on appeal:http://www.righthandfirm.com/blog/2006/09/california_bad_faith_insurance.html
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Tina, thank you for all your help (more than 38 bucks worth i'm sure). I feel a little better now...happy trails...i gave you a super happy face...tom
Hello again, Tom.I am so glad I could help!Good luck to you and take care. I hope you are able to get the denial reversed on appeal.
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