Workers' Compensation Discussion Forums
sdi stopped payment pending qme results - Printable Version

+- Workers' Compensation Discussion Forums (https://www.workerscompensation.com/forums/general)
+-- Forum: Category (https://www.workerscompensation.com/forums/general/forumdisplay.php?fid=3)
+--- Forum: Injured Worker Forum (https://www.workerscompensation.com/forums/general/forumdisplay.php?fid=4)
+--- Thread: sdi stopped payment pending qme results (/showthread.php?tid=13097)



sdi stopped payment pending qme results - kylecalifornia - 12-17-2011

the California state disability board ordered a QME while I have been receiving benefits so I went. it was 15 days ago and I have no answers. they wont issue my benefits to me until they come to a conclusion. I called the dr.s office i went to for the QME and they assured me that they sent the results off to the state for review. how long does EDD have to make a determination so I can re-continue getting my bi-weekly benefits? Is this the normal procedure for EDD to do?


RE: sdi stopped payment pending qme results - 1171 - 12-17-2011

this board is for those with work injury issues.
California's Employment Development Department has separate regulations and rules governing disability payments for non-work injuries.
I was not aware they also use a QME process.

are you sure you are not confusing SDI benefits with worker's compensation benefits? workers comp also pays Temporary disability but for work injuries only.
QME reports are used by workers comp for work injuries and may be reviewed by the Department of Workers Compensation as well as the employer's insurance carrier.

for SFI information you might find more here
http://www.edd.ca.gov/Disability/FAQ_DI_Benefits_Payments.htm

it's probably normal when EDD has questions about the SDI benefits to get a second medical opinion.
there is likely no time limit.
you might look into filing an appeal.
http://www.edd.ca.gov/Disability/Appeals.htm



RE: sdi stopped payment pending qme results - kylecalifornia - 12-17-2011

It is SDI that did the QME, I had no idea they did them until i received the phone call and letter from SDI. Maybe its W/C requesting it through SDI?



RE: sdi stopped payment pending qme results - 1171 - 12-17-2011

(12-17-2011, 11:18 AM)kylecalifornia Wrote: It is SDI that did the QME, I had no idea they did them until i received the phone call and letter from SDI. Maybe its W/C requesting it through SDI?

nope. workers comp handles their own directly.
learn something new everyday.
sorry, i am not familiar with SDI QME rules.


RE: sdi stopped payment pending qme results - chrischris - 12-17-2011

 

Back to Top


X. How to File a Claim for State Disability Insurance Benefits.

Suppose an injured worker has received a delay letter saying that the insurance company cannot make a decision yet, but will notify her of acceptance (or not) of her claim within 90 days. Your client is currently unable to work at all and will be in dire straits financially if she has no income. She wants to know what her options might be as far as income.

As mentioned earlier in this Manual, you should advise clients to file claims for SDI whenever filing for workers' compensation in order to freeze their employment and income history. This will be important if your client is still unable to work due to disability at the end of the 2-year limit.

Additionally, your client may be eligible to receive state disability benefits while her workers' compensation case is pending. The employee must agree ahead of time to reimburse the unemployment disability carrier with any award from workers' compensation. UIC 2629.1. If your client's workers' compensation award is less than it would have been under SDI, she may be entitled to the difference from SDI. UIC 2629.

Benefits: The amount of SDI benefits are almost equal to workers' compensation temporary disability benefits. UIC 2655. SDI payments last for 52 weeks. Note, though, that SDI does not include any medical treatment benefits -- just income.
A. Find out if your client is eligible for SDI. SDI benefits can be paid only after your client meets all of the following requirements:

She must be unable to do her regular or customary work for at least eight consecutive days.
She must have been employed or actively looking for work at the time she became disabled.
She must have lost wages because of her disability or, if unemployed, have been actively looking for work.
She must have earned at least $300 from which SDI deductions were withheld during a previous period.
She must be under the care and treatment of a licensed doctor or accredited religious practitioner during the first eight days of her disability. (The beginning date of a claim can be adjusted to meet this requirement.) She must remain under care and treatment to continue receiving benefits.
She must complete and mail a claim form within 49 days of the date she became disabled or she may lose benefits.
Her doctor must complete the medical certification of her disability. A licensed midwife, nurse-midwife, or nurse practitioner may complete the medical certification for disabilities related to normal pregnancy or childbirth. (If client is under the care of a religious practitioner, request a "Practitioner's Certificate," DE 2502, from the SDI office. Certification by a religious practitioner is acceptable only if the practitioner has been accredited by Employment Development Department.)
Note: The EDD may require an independent medical examination to determine your client's initial or continuing eligibility.

Note: Your client should apply for benefits even if she is not sure she is eligible. If she is found to be ineligible for all or part of a period claimed, she will be notified of the ineligible period and the reason.


RE: sdi stopped payment pending qme results - kylecalifornia - 12-19-2011

(12-17-2011, 04:31 PM)chrischris Wrote:  

Back to Top


X. How to File a Claim for State Disability Insurance Benefits.

Suppose an injured worker has received a delay letter saying that the insurance company cannot make a decision yet, but will notify her of acceptance (or not) of her claim within 90 days. Your client is currently unable to work at all and will be in dire straits financially if she has no income. She wants to know what her options might be as far as income.

As mentioned earlier in this Manual, you should advise clients to file claims for SDI whenever filing for workers' compensation in order to freeze their employment and income history. This will be important if your client is still unable to work due to disability at the end of the 2-year limit.

Additionally, your client may be eligible to receive state disability benefits while her workers' compensation case is pending. The employee must agree ahead of time to reimburse the unemployment disability carrier with any award from workers' compensation. UIC 2629.1. If your client's workers' compensation award is less than it would have been under SDI, she may be entitled to the difference from SDI. UIC 2629.

Benefits: The amount of SDI benefits are almost equal to workers' compensation temporary disability benefits. UIC 2655. SDI payments last for 52 weeks. Note, though, that SDI does not include any medical treatment benefits -- just income.
A. Find out if your client is eligible for SDI. SDI benefits can be paid only after your client meets all of the following requirements:

She must be unable to do her regular or customary work for at least eight consecutive days.
She must have been employed or actively looking for work at the time she became disabled.
She must have lost wages because of her disability or, if unemployed, have been actively looking for work.
She must have earned at least $300 from which SDI deductions were withheld during a previous period.
She must be under the care and treatment of a licensed doctor or accredited religious practitioner during the first eight days of her disability. (The beginning date of a claim can be adjusted to meet this requirement.) She must remain under care and treatment to continue receiving benefits.
She must complete and mail a claim form within 49 days of the date she became disabled or she may lose benefits.
Her doctor must complete the medical certification of her disability. A licensed midwife, nurse-midwife, or nurse practitioner may complete the medical certification for disabilities related to normal pregnancy or childbirth. (If client is under the care of a religious practitioner, request a "Practitioner's Certificate," DE 2502, from the SDI office. Certification by a religious practitioner is acceptable only if the practitioner has been accredited by Employment Development Department.)
Note: The EDD may require an independent medical examination to determine your client's initial or continuing eligibility.

Note: Your client should apply for benefits even if she is not sure she is eligible. If she is found to be ineligible for all or part of a period claimed, she will be notified of the ineligible period and the reason.

Very informative. Thank you...
Workers compensation denied my claim in October. I just called their automated system to see if anything has changed and they have made medical payments. They made the medical payments 10 days after my edd QME appointment. I am hoping this is a good sign and that they have accepted my claim and are now going to pay benefits.