Section 50.48. Claim for benefits.

 

(1)   Claimant's application. A claimant shall establish that he or she meets all the requirements to receive benefits under this subchapter. A claimant shall apply for benefits by making an application on the form approved by the department or by contacting the third-party administrator.

(2)   Medical reports. Except as the department shall otherwise direct in writing, the claimant, at his or her own cost, shall be responsible for obtaining and delivering to the department medical reports from physicians approved or appointed by the department supporting the application, as provided in s. ETF 50.50 (6) .

(3)   Employer statement.

(a) The department shall provide the employer with a form for the employer to state the information necessary under s. ETF 50.50 (5) .

(b) Each participating employer shall provide and state the following information to the department in response to an application for LTDI benefits:

1. The employer shall state the date on which the employee last rendered services.

2. The employer shall state the employee's last day paid and provide an explanation if this date is different from the date the employee last rendered services. The employer's explanation shall expressly identify payments including accumulated sick leave, other paid leave, vacation, compensatory time or worker's compensation temporary disability benefits which caused the last day paid to follow the date the employee last rendered services.

3. The employer shall state whether the employer has paid to the employee all earnings to which the employee is entitled and provide an explanation of earnings to which the employee remains entitled.

4. The employer shall describe the employee's present employment status, expressly including, if applicable, a statement that the claimant's employment is terminated or that the claimant is on a leave of absence and is not expected to resume active service. The statement shall include the date of the termination or of commencement of leave of absence, as applicable.

5. The employer shall state in writing on the employer statement form the reason for the employee's termination or leave of absence.

6. For a claimant who is an elected official only, the employer shall state the date of the end of the elected official's term of office.

(c) If an employer fails to provide the required report within 90 days of the department's request for an employer statement, the department may charge the employer $20 for each calendar day following until the report is received by the department, plus interest at 0.04% per day on the unpaid balance of any charges under this paragraph as provided in s. 40.06 (3) , Stats. This paragraph shall not in any way limit the employer's liability to a claimant whose application is void under sub. (5) as a result of the employer's failure to provide information required under this subsection.

(4)   Department determination.

(a) The department shall report its determination to grant or deny each application for LTDI benefits to the employer and the claimant. A claimant or employer who wishes to contest the department's findings shall make a timely appeal to the group insurance board. If no timely appeal is filed, the department's determination to grant or deny the application for LTDI benefits shall be final.

(b) The department shall deny the application for LTDI benefits if it determines the claimant does not meet the applicable requirements or if any of the following apply:

1. The department receives a statement from the employer certifying that the employee's participating employment has not been terminated, or the employee is on a leave of absence and is expected to resume active service.

2. The department determines the claimant fails to meet the minimum service requirements under s. ETF 50.50 (2) (b) and the physicians deny that the medically determinable impairment described in the claimant's application is a result of employment as a participating employee with the employer.

3. The department receives a written statement from the employer on the employer statement form indicating that the employee's termination or leave of absence was for a reason other than a medical issue.

(c) If the department's denial is based solely on par. (b) 1. or 3. , or both, the claimant may appeal to the group insurance board. The group insurance board's decision shall include a finding as to whether the employer's responses on the employer statement form were reasonable and correct. If the group insurance board determines that the employer's responses were unreasonable and incorrect, the group insurance board decision shall include an order to the employer to amend the statement and an order to the department to process the LTDI application when the amended statement is received.

(5)   Incomplete application void. Except as provided in sub. (6) , if any of the evidence required by subs. (1) to (3) and s. ETF 50.50 (1) to (6) is not received within 12 months after the date the claimant's application for LTDI benefits is received by the department, the application shall be canceled and void. The claimant may reapply for LTDI benefits if otherwise still eligible.

(6)   Death of claimant.

(a) If a claimant dies prior to the date a decision regarding the approval or disapproval of an application for LTDI benefits becomes final under sub. (4) (a) , the application is deemed to have been approved prior to the claimant's death if all of the following apply:

1. The claimant was eligible for the disability benefit.

2. Prior to the date of the claimant's death, the department received an application for LTDI benefits in the form approved by the department and at least one written qualifying medical certification under s. ETF 50.50 (6) .

3. The claimant died on or after the date which would have been the effective date of the LTDI benefits.

(b) For the purposes of this subsection, a claimant is conclusively presumed not eligible for LTDI benefits if the application is based on an alleged medically determinable impairment which was the basis for a previous application which the department denied.

(c) This subsection shall not be construed to create any entitlement for any person to receive LTDI benefits for any period beyond the applicable termination date under s. ETF 50.56 .

(d) Payment for LTDI benefits owed to the deceased claimant under this subsection shall be made to the claimant's estate, regardless of any beneficiary under s. 40.02 (8) , Stats.

History: Emerg. cr. eff. 10-15-92; cr. Register, May, 1993, No. 449 , eff. 6-1-93; cr. (4) (c), Register, December, 1998, No. 516 , eff. 1-1-99; CR 02-057 : am. (3) (a), (b) and (c) and (4) (b) 1. to 3. and (c), r. and recr. (3) (b) 5. and 6, r. (3) (b) 7., to 10., Register November 2002 No. 563 , eff. 12-1-02; CR 14-055 : am. (1), (3) (a), (b) 5., (4) (b) 3., (c) Register May 2015 No. 713 , eff. 6-1-15.

Note

Form ET-5313, "Long-Term Disability Benefit Claim Form" may be obtained at no charge by writing to: department of employee trust funds, P.O. Box 7931, Madison, Wisconsin 53707-7931, or by calling [phone] or toll free at [phone]. Microsoft Windows NT 6.1.7601 Service Pack 1 Form ET-5338, "LTDI Medical Report" is sent to the applicant with the LTDI claim form ET-5313. Form ET- 5353, "LTDI Special Disability Medical Report" will be sent with the LTDI claim form upon request of a protective occupation participant. Microsoft Windows NT 6.1.7601 Service Pack 1 Form ET-5315, "Employer Statement (LTDI)," is sent to the employer by the department after a claim form is received. Microsoft Windows NT 6.1.7601 Service Pack 1