Common Employee Claim Questions
Q. Can I access my claim status online?
A. At this time, we do not offer this feature to individual employees. Your employer can check your claims status on your behalf, or you may contact USAble Life Customer Care directly at email@example.com or by calling 800-370-5856.
Q. Whom should I contact to check the status of my claim?
A. Our Customer Care team is happy to check your claim status for you. Call at your convenience, Monday through Friday, 8:00 a.m. to 5:00 p.m. CST at 800-370-5856, or email firstname.lastname@example.org. We’re standing by, ready to help!
Q. Is someone assigned to my claim?
A. Yes. All claims are reviewed for completeness and assigned to a dedicated claims examiner. Your claims professional will manage your claim from start to finish, coordinating efforts to resolve your claim quickly and efficiently.
Q. How do I file a claim?
A. Email your claim to email@example.com. Claim forms can be found on our website at usablelife.com. Choose the Individual tab, select Forms and Brochures, search for your State, and enter the keyword Forms or Claim. Remember that you will also need an Authorization for Release of Medical Records form attached to your claim.
Q. What is the average processing time for claims?
A. A decision to pay, pend*, or deny a claim is reached on 95% of all claims within five business days of receipt.
Q. What causes delays in the claims process?
A. If the claims examiner needs more information from you (the employee), your employer, or another resource, it may delay the claim. In addition, if we have to request medical records, the processing of your claim may be delayed for several weeks or months.
Q. What taxes are withheld from my benefits?
A. The following taxes may be withheld:
- Social Security and Medicare Taxes (FICA Taxes) are withheld at the current rate on taxable benefits
- Federal Income Tax is withheld only at the insured’s request. The insured submits Form W4-S to make this request
- Benefits may be subject to other taxes such as Federal Unemployment Tax, State Unemployment Tax, State Income Tax, etc
Common Employer Claim Questions
Q. Who prepares employee W-2s?
A. Employers prepare W-2s and provide them to their employees. If requested, USAble Life will prepare your employee W-2s at no additional cost. Employers will need to submit a W-2 Agreement designating USAble Life as the preparer (this agreement is included in your application, or can be requested from USAble Life Policy Services). If you use a payroll service, please discuss W-2 responsibilities with them. Most payroll services require that employers prepare the forms.
Q. Whom do I contact if I cannot access all of my claim information?
A. Our USAble Life Customer Care team will be happy to help you access your claim information. Please email firstname.lastname@example.org or call 800-370-5856 with your group number.
Benefit-Specific Claim Questions
Short Term Disability
Q. I’m pregnant. When should I submit my Short Term Disability (STD) claim?
A. If you have scheduled a cesarean section, you may turn in the claim form no earlier than one week prior to the procedure. If you are expecting a normal delivery, the claim form should be submitted after the delivery to ensure the information on the form is accurate.
Q. How do I get an STD claim form?
A. STD claim forms can be found on our website at usablelife.com. Choose the Individual tab, select Forms and Brochures, search for your State, and enter the keyword Forms or Claim. You can also contact your employer or call USAble Life Customer Care at 800-370-5856.
Q. How do I file an STD claim?
A. Once the claim form is complete, you can submit that information and any attachments to:
- Attention: Claims Department
- Mail: P.O. Box 1650 | Little Rock, AR 72203
- Email: email@example.com
- Fax: (501) 235-8417
Q. When should I file an STD claim?
A. STD claims should be submitted as soon as the disability occurs to ensure a claim decision is made in a timely manner. If you have a planned surgery, delivery, etc., you can submit the claim no more than 30 days before the scheduled event.
Q. What is an elimination period?
A. An elimination period is the number of days you must be disabled before benefits are payable. No benefits are payable during the elimination period.
Q. How long does it take for a decision to be made on an STD claim?
A. USAble Life strives to make the initial decision on STD claims within five business days of receiving all information needed. Each claim is different, and we may request additional information to make a decision on a claim.
Q. When does USAble Life consider an insured employee disabled?
A. An insured employee is considered disabled on the date they meet the definition of disability as outlined in the policy. Medical records and information from physician(s) may aide in determining the date of disability.
Q. How long can an insured employee receive STD benefit payments?
A. Once the elimination period is satisfied, STD benefits are payable up to the maximum benefit period, as long as the insured continues to be disabled under the terms of the policy. Periodic updates will be requested to support the insured’s continued disability status.
Q. Who should notify USAble Life of return to work?
A. The insured employee should notify USAble Life as soon as he/she plans to return to work. The employer should notify USAble Life as soon as the insured has returned to work.
Q. How much will my STD benefits be?
A. Depending on the specific policy, the benefit may be either a percentage of pre-disability earnings, an elected amount, or a flat amount. In some cases, the benefit may be reduced by other income benefits the insured is entitled to receive. Please refer to the specific policy, and contact our Customer Care team at 800-370-5856 if you have questions.
Q. How are maternity claims handled?
A. Pregnancy is considered the same as any other illness under the terms of the policy. As such, standard medical disability guidelines are considered when determining the duration of the disability. Unless there are any specific state guidelines, the standard medical disability guideline for a normal pregnancy, vaginal, or C-section delivery is (six) 6 weeks postpartum. The actual duration can vary, resulting in either a shorter or a longer period based on the medical documentation provided. If the insured employee returns to work or is released to return to work prior to the six weeks postpartum date, the duration may be shorter. If disability is extended beyond six weeks postpartum, specific medical documentation supporting the medical need for the extension is required.
Q. How will an insured employee receive benefits?
A. Benefit checks are payable to the insured employee and are typically mailed to the employee’s mailing address listed on the claim form.
Q. How often do I need to complete an update form on my STD claim?
A. Update forms are usually mailed to the employee four to six weeks after the beginning disability date. This may vary based on the individual claim.
Q. Are STD benefits taxable?
A. STD benefits are taxable as follows:
- When the employer pays any portion of the premium, the percentage of coverage paid by the employer is taxable
- When the employee pays any portion of the premium with pretax dollars, the percentage of coverage paid by the employee with pretax dollars is taxable
Temporary Disability Insurance
Q. What is Temporary Disability Insurance?
A. TDI, like workers’ compensation and unemployment insurance, is a wage replacement program. This means that if you are unable to work due to an off-the-job sickness or injury, and you meet the qualifying conditions of the law, you will be paid disability or sick leave benefits to partially replace the wages you lost. TDI does not include medical care.
Q. Who provides TDI benefits?
A. Your employer must provide TDI (or sick leave) benefits when you are unable to work due to a disability. The State of Hawaii does not pay TDI benefits; it makes sure every employer subject to the law provides benefits for the employer’s employees. If your employer does not provide these benefits, report this immediately to the nearest Disability Compensation Division (DCD) office.
Q. Who pays for the cost of TDI benefits?
A. Your employer may pay the entire cost, or may require you to share in the cost. If you share in the cost, your employer may deduct one-half the premium, but not more than 0.5% of your weekly wages up to the maximum set annually by DCD. If your employer deducts more than the law prescribes, notify DCD immediately. No contributions can be withheld from an employee who does not meet the law’s eligibility requirement.
Q. Who is covered by TDI?
A. Any employee who meets the eligibility requirements, whether hired or on a part-time basis, must be provided TDI coverage by their employer.
Q. What are the eligibility requirements?
A. You must have been employed in Hawaii at least 14 weeks, during each of which you were paid for 20 hours or more in the 52 weeks preceding the first day of disability and earned at least $400. The 14 weeks need not be consecutive or with only one employer.
Q. What other requirements must be met?
A. You must meet the following conditions in addition to meeting the eligibility requirements:
- Your injury or illness is not work related (not caused by your job)
- Your injury or illness prevents you from performing your regular work
- Your disability is certified by a licensed physician, surgeon, dentist, chiropractor, osteopath, naturopath, or an accredited practitioner of a faith-healing group
- You were employed immediately before the date you suffered your injury or illness, or if you were separated from your job, your disability occurred within two weeks from your separation date.
Q. How much benefit am I entitled to?
A. Your employer has a statutory plan that provides benefits according to minimum benefit standards.
- Cash benefits of 58% of your average weekly wages rounded to the next higher dollar, but not more than the maximum weekly benefit amount annually set by DCD
- Benefits from the eighth day of disability; in other words, there is a seven consecutive-day waiting period
- A maximum of 26 weeks of payments during a benefit year
- Payment will be made by USAble Life within 10 business days of receipt of a valid claim
Q. What do I do if I suffer a disability and need to file a TDI claim?
A. If you suffer a disabling non-occupational injury or sickness, notify your employer immediately and ask for Form TDI-45, Claim for Disability Benefits.
- Complete Part A of the claim form, Claimant’s Statement
- Take the form to your doctor to complete Part C, Doctor’s Statement
- Have your employer complete Part B, Employer’s Statement
- Submit completed forms to USAble Life
Q. How soon should I file a TDI claim?
A. The law requires that you file your claim within 90 days from the date you were disabled. If you file your claim after 90 days, you may lose part of your benefits unless good cause can be shown. If you file your claim 26 or more weeks after your disability, you will not be entitled to any benefits. To avoid partial or complete loss of benefits, file your claim within 90 days.
Q. What if I am denied TDI benefits or disagree with my weekly benefit amount?
A. USAble Life is required to send you written notices (three copies) if your claim is denied. If you disagree with the denial, you may appeal by explaining why you disagree on the notice and sending two copies to DCD. You have 20 days to appeal. DCD will notify you of the time and place of the appeal hearing. An impartial referee will hear your case. Although it is not required, you may have an attorney represent you at the hearing. If you do not agree with the referee’s decision, you may further appeal to the circuit court. You may appeal to DCD if you disagree with the amount of benefits paid to you by USAble Life. Bring evidence such as pay slips or check stubs to prove that you are entitled to more benefits.
Q. How does USAble Life determine if someone is ineligible for TDI benefits?
A. You are ineligible for TDI benefits if:
- You performed work for pay during your period of disability
- You were denied unemployment insurance benefits because of a work stoppage due to a labor dispute
- Your injury was willfully and intentionally self-inflicted or received while committing a criminal offense
- You received or will receive unemployment insurance, workers’ compensation, or federal disability benefits
Q. What is the Special Disability Fund and who may file for benefits?
A. A Special Disability Fund was established through assessments imposed on all employers subject to the TDI law. According to the law, this fund can only be used to pay benefits to:
- Employees whose employers have failed to provide TDI coverage or who have gone bankrupt
- Unemployed claimants who, while receiving unemployment insurance benefits, became disabled and were held ineligible for further benefits solely due to the disability
If you fall in either one of the above categories at the time you become disabled, notify the nearest DCD Office immediately. DCD will advise you on how to file a claim against the Special Disability Fund and the amount and direction of your weekly benefit amount.
Q. What is notice of insurance?
A. Your employer should have a “Notice to Employees” poster visible around their place of business that informs all employees that they are being provided TDI coverage in accordance with TDI law. If the poster does not contain information on the benefit entitlement, ask your employer for details. If no poster is visible, call this to your employer’s attention or notify the nearest DCD Office.
Q. What happens if I am paid or receive cash benefits from other sources?
A. If you were paid or expect to be paid cash benefits from other sources (except your private income protection plan) for a disability that your employer or the insurance carrier has already paid you TDI benefits, USAble Life has the right to claim or subrogate the amount paid to you. Subrogation may also extend to workers’ compensation benefits if such benefits are awarded subsequently and cover the same disability period.
Q. Can I suffer any penalties?
A. You will be ineligible for benefits for an indefinite period if you knowingly make false statements, misrepresent a fact, or fail to disclose a material fact in order to obtain unentitled benefits. You will be required to repay all improperly received benefits.
Life and Accidental Death & Dismemberment
Q. When determining primary beneficiary percentage, what should I keep in mind?
A. Primary beneficiary amounts should total 100%.
Q. What about contingent beneficiary percentage?
A. Contingent beneficiary amounts should also total 100%.
Q. How does a contingent beneficiary become eligible to receive a benefit?
A. A contingent beneficiary will only be paid if there is no surviving primary beneficiary.
Q. What if I have multiple beneficiaries and/or more pass away?
A. The percentage designation would change and be evenly distributed to your remaining primary beneficiaries.
Q. What occurs if the beneficiary or beneficiaries are minors?
A. If a minor beneficiary is listed, we can only pay the benefit through the Uniform Transfer to Minors Act (UTMA) or legal conservatorship. The UTMA requires the guardian of the minor to complete an affidavit and can only be used on claims under the state threshold, generally $10,000. Legal conservatorship requires the assistance of an attorney, and the courts must appoint a conservator of the minor’s estate; this is a separate legal status as that of a natural parent or custodian.
Q. What if my beneficiary is not a U.S. citizen?
A. A member can list someone who is not a U.S. citizen and does not have a social security number. It is recommended that USAble Life have as much information as possible on the beneficiary (full name, address, phone number, etc.) so that we will be able to locate and identify the beneficiary in the event of a claim. Other information will need to be validated before payment can be made.
Q. What happens if there is no beneficiary on file?
A. If there is no beneficiary listed at the time of loss, USAble Life will pay according to the policy provisions. Most policies will list a class of survivors, such as spouse, children, parents, siblings, or the estate. Some policies only allow for payment to the estate. If we are paying by the policy provisions, we will need to obtain affidavits of survivorship, and if needed, these will be initiated by the claims examiner.
Q. Can a trust be considered a beneficiary?
A. Trusts can only be paid if the trust is the listed beneficiary. At time of the claim, we would need copies of the trust documents listing the trustee and the beneficiary’s statement of claim completed by the trustee.
Q. Can an estate be eligible to receive life proceeds?
A. Estates can be paid as the listed beneficiary based on policy provisions if there is no listed beneficiary or other class of survivor. At time of the claim, USAble Life will need copies of the estate documents listing the executor and the beneficiary’s statement of claim completed by the executor. Small estate affidavits can be used based on the amounts and specific state laws.
Q. Can a portion of the benefit proceeds be assigned to a funeral home or comparable entity to help with funeral arrangements?
A. Yes. Funeral home assignments can be completed by listed beneficiaries. Minors cannot enter into a legal contract and cannot sign an assignment. If there is more than one beneficiary, all beneficiaries will need to sign the assignment; otherwise, the entire assignment will be paid by the beneficiaries who did sign.
Supplemental (Wellness, Accident, Critical Illness, Hospital)
Q. Do I have to wait until I have all of the bills before I can file an accident or cancer claim?
A. No. You may file the claim and send the bills as they are received. Always include your policy number and claim number on each bill submission.
Please refer to the specific policy for questions about the following items:
- Pre-existing provisions
- Elimination period
- Other income offsets
- Termination of coverage and/or benefits
If you have other general questions, please contact USAble Life Customer Care at 800-370-5856. Please be aware that we cannot answer hypothetical claim questions.
*Pended claim: If the examiner needs information from an outside source (e.g., medical provider, employer), the information will be requested, and the claim will be put in a pended status for up to 45 days until the information is received. The response time for medical record(s) requests varies and may require an extension of the pended status