California Code of Regulations › Title 22 - Social Security › Division 1 - Employment Development Department › Subdivision 1 - Director of Employment Development › Division 1 - Unemployment and Disability Compensation › Part 2 - Disability Compensation › Chapter 2 - Disability Benefits › Article 4 - Filing, Determination and Payment of Disability Benefit Claims › Section 2706-7 - Payment of Family Temporary Disability Insurance Benefits Pending Appeal by Claimant

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
						  Scope. This section interprets whether Family Temporary Disability Insurance
						  (also known as Paid Family Leave) benefit payments continue in situations where
						  the department initially determines a claimant is eligible for benefits, but
						  subsequently determines the claimant is ineligible or disqualified from
						  benefits, and the claimant files an appeal from the subsequent
						  determination.
(b) General. If the
						  department initially determines that a claimant is eligible for and has been
						  paid Family Temporary Disability Insurance benefits, and then subsequently
						  determines that the claimant is ineligible to receive or subject to a reduction
						  of further benefits, and the claimant files a timely appeal from the subsequent
						  determination, within 30 days pursuant to Unemployment Insurance Code Section
						  2707.2,
						  and files a written election with the department on a prescribed form ("Notice
						  of Right to Continue Paid Family Leave Benefits Pending Appeal", DE 6315DF Rev.
						  9-09) to have benefits continued and files continued claims pending disposition
						  of the appeal, the department shall continue to pay benefits until the appeal
						  has been resolved by the decision of an administrative law judge, except that
						  benefit payments shall cease if the appeal is dismissed or if a criminal
						  complaint for fraud is filed against the claimant under Section
						  2101 of the code (see subdivision
						  (c) of Section
						  1263, Section
						  2602, and subdivision (a) of
						  Section 2675 of the code).
(c) Claimant Initially Determined Eligible.
						  The department has initially determined that a claimant is eligible for Family
						  Temporary Disability Insurance benefits if, after the filing of a first claim,
						  the department determines that all of the following conditions exist:
(1) The claimant is providing care for a
						  seriously ill child, spouse, parent, grandparent, grandchild, sibling,
						  registered domestic partner, or bonding with a new child.
(2) The claimant has received one or more
						  Family Temporary Disability Insurance benefit payments.
(3) The claimant has filed a claim in
						  accordance with authorized regulations, which appear in Title 22, California
						  Code of Regulations, Division 1, Part 2, Chapter 2, Article 4.
(4) The claimant has a monetarily valid
						  claim.
(5) The claimant has not
						  exhausted the maximum benefit amount for the period of family care leave of the
						  claim.
(6) The initial
						  determination is not subject to reconsideration under subdivision (a) of
						  Section 2707.5 of the code.
(7) The initial benefit amount has not been
						  recomputed under subdivision (b) of Section
						  2707.5 of the code and determined
						  to be monetarily invalid.
(8) The
						  department has not determined that the claimant is ineligible for benefits
						  based on a new set of facts or conditions unless the new determination of
						  ineligibility meets all the other conditions of this subdivision.
(9) The claimant is otherwise eligible.
EXAMPLE 1. Claim Filing. Claimant A files a first
							 claim for Family Temporary Disability Insurance benefits to provide care for a
							 seriously ill family member which is received on September 20, 2007, and
							 postmarked September 15, 2007. Claimant A indicates family care leave beginning
							 June 30, 2007. The department determines Claimant A does not have good cause
							 for exceeding the 41 day filing period and under Section
							 3301(e) of the
							 code gives the claim an effective date of July 29, 2007. Claimant A is paid
							 Family Temporary Disability Insurance benefits based on July 29, 2007. Claimant
							 A appeals the department's denial of benefits for the days from June 30 through
							 July 28, 2007. The department has not determined that Claimant A was initially
							 eligible for those days. Therefore, pending decision on the appeal, Claimant A
							 is not entitled to receive benefits for any day prior to July 29, 2007. The
							 days following July 29, 2007 are not affected by the back dating issue raised
							 by Claimant A's appeal, and Claimant A is entitled to continued payment of
							 Family Temporary Disability Insurance benefits for the days following July 29,
							 2007.
(Note: The received and postmark dates for Family
							 Temporary Disability Insurance claims are established by utilizing a five day
							 processing standard for the automated claim form. On the day that the
							 department receives a Family Temporary Disability Insurance claim, an automated
							 procedure establishes the FTDI claim date as of the five days preceding receipt
							 of the completed claim. For example, if the department receives a completed
							 FTDI claim on July 15, 2007 the automated procedure establishes an FTDI claim
							 date as of July 10, 2007.)
EXAMPLE 2. Claim Filing. Claimant B files a first
							 claim for Family Temporary Disability Insurance benefits to bond with a new
							 child born on May 19, 2007. Claimant B previously received Disability Insurance
							 benefits during her pregnancy with this child. Claimant B submits her
							 application for Family Temporary Disability Insurance benefits which was
							 received September 20, 2007 and postmarked September 15, 2007. Claimant B is
							 requesting to begin her Family Temporary Disability Insurance claim on June 30,
							 2007. The department determines that Claimant B does not have good cause for
							 exceeding the 41 day filing period and under Section
							 3301(e) of the
							 code gives the claim an effective date of August 5, 2007. Claimant B is paid
							 benefits based on August 5, 2007. Claimant B appeals the department's denial of
							 benefits for the days between June 30, 2007 to August 4, 2007. The department
							 has not determined that Claimant B was initially eligible for those days.
							 Therefore, Claimant B is not entitled to receive benefits for any day prior to
							 August 5, 2007, pending decision on the appeal. The days following August 5,
							 2007 are not affected by the backdating issue raised by Claimant B's appeal and
							 she is entitled to receive continued benefits after August 5, 2007.
(Note: The received and postmark dates for Family
							 Temporary Disability Insurance claims are established by utilizing a five day
							 processing standard for the automated claim form. On the day that the
							 department receives a Family Temporary Disability Insurance claim, an automated
							 procedure establishes the FTDI claim date as of the five days preceding receipt
							 of the completed claim. For example, if the department receives a completed
							 FTDI claim on July 15, 2007 the automated procedure establishes an FTDI claim
							 date as of July 10, 2007.)
EXAMPLE 3. Claim Filing. The department determines
							 Claimant D is initially eligible for Family Temporary Disability Insurance
							 benefits. Claimant D receives benefits for 28 days, but does not return the
							 continued claim for the next period of payment until after the 20-day filing
							 period. The department determines that Claimant D does not have good cause for
							 late filing and holds Claimant D ineligible because the claim was not filed
							 timely in accordance with Section
							 2706-3 of these regulations.
							 Claimant D files an appeal. Since the department has determined that Claimant D
							 was initially eligible, Claimant D is entitled to receive benefits for the
							 disallowed period pending decision on the appeal.
EXAMPLE 4. Late Medical Extension. The department
							 determines Claimant E is initially eligible for Family Temporary Disability
							 Insurance benefits to care for his ill father with chronic renal failure.
							 Claimant E receives benefits for 25 days, however, Claimant E continues to
							 provide care beyond the 25 days that were initially certified by the physician.
							 Claimant E does not return his medical extension form until after the 20-days
							 commenced from the date the medical extension form was issued. The department
							 determines that Claimant E does not have good cause for late filing and holds
							 Claimant E ineligible because the medical extension was not received timely in
							 accordance with Section
							 2706-3 of these regulations.
							 Claimant E files an appeal. Since the department has determined that Claimant E
							 was initially eligible, Claimant E is entitled to receive Family Temporary
							 Disability Insurance benefits for the disallowed period pending decision on the
							 appeal.
EXAMPLE 5. Reconsideration of Determination. Claimant
							 F files a first claim for Family Temporary Disability Insurance benefits to
							 care for a seriously ill mother with cancer. The Department pays Family
							 Temporary Disability Insurance benefits to Claimant F for 20 days and
							 subsequently discovers that Claimant F is being paid temporary disability
							 indemnity under workers' compensation for the same period and weekly rate as
							 the Claimant's Family Temporary Disability Insurance benefits. The department
							 reconsiders the determination and determines that Claimant F is ineligible
							 under Section
							 3303.1 of the code for the period
							 of family care leave because of the duplication of benefits. Claimant F
							 appeals. Since under subdivision (a) of Section
							 2707.5 of the code the department
							 may reconsider any benefit determination prior to filing an appeal, the initial
							 determination was not final and claimant F is not entitled to receive Family
							 Temporary Disability Insurance benefits pending decision on the appeal.
EXAMPLE 6. Reconsideration of Computation. Claimant G
							 files for and is paid Family Temporary Disability Insurance benefits. While
							 Claimant G is in continued claim status, the department recomputes Claimant G's
							 claim and determines under Section
							 2652 of the code that Claimant G
							 does not have sufficient qualifying wages in the disability base period to have
							 a valid claim. Claimant G appeals. Since, under subdivision (b) of Section
							 2707.5 of the code the department
							 may re-compute a claim within one year from the beginning date of a disability
							 benefit period, the initial computation was not final, and Claimant G is not
							 entitled to receive Family Temporary Disability Insurance benefits pending
							 decision on the appeal.