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 2712-2 - Dispute Between Department and a Voluntary Plan or Different Voluntary Plans Where Claim Filed Against a Voluntary Plan

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) If an individual files a claim for
						  disability benefits against a voluntary plan and the voluntary plan insurer or
						  self-insurer determines that the claimant is eligible for disability benefits,
						  but that such benefits are payable from the Disability Fund or another
						  voluntary plan, the voluntary plan insurer or self-insurer with whom the claim
						  was filed shall immediately forward a copy of the claim and any medical and
						  other records relating thereto to the department or other voluntary plan
						  insurer or self-insurer, as the case may be, with a request that benefits be
						  paid from the Disability Fund or the other voluntary plan. If any payment has
						  been made from the voluntary plan against which the claim was filed, a
						  statement of such payments and a request for reimbursement at the Disability
						  Fund rate or other voluntary plan rate shall also be forwarded with the copy of
						  the claim. If the department or other voluntary plan insurer or self-insurer
						  concedes coverage and eligibility, prompt reimbursement shall be made to the
						  voluntary plan with which the claim was filed at the Disability Fund rate and
						  period or other voluntary plan rate and period, as the case may be, and the
						  claimant shall be promptly paid the accumulated excess of benefits, if any, to
						  which he or she is entitled. If the department or other voluntary plan insurer
						  or self-insurer denies coverage, it shall immediately so notify in writing the
						  voluntary plan insurer or self-insurer with whom the claim was filed, and the
						  claimant, giving its reason for the denial and, in such event, the voluntary
						  plan insurer or self-insurer shall immediately pay benefits under the claim at
						  not less than the Disability Fund rate.
(b) If the department or the other voluntary
						  plan insurer or self-insurer fails to give notice of acceptance or denial of
						  coverage within twenty-five (25) days after a copy of the claim is mailed or
						  delivered to it as provided in subdivision (a) of this section, such failure
						  shall be deemed to be a denial of coverage and the voluntary plan insurer or
						  self-insurer with whom the claim was filed shall immediately pay benefits under
						  the claim at not less than the Disability Fund rate.
(c) Subdivisions (a) and (b) of this section
						  shall also apply to claims for Family Temporary Disability Insurance
						  benefits.
(d) Disclosure
						  authorizations for Family Temporary Disability Insurance claims. Voluntary
						  plans shall obtain a care recipient's, as defined in code section
						  3302, subdivision (a),
						  authorization to disclose his or her medical information before forwarding any
						  medical records to the department. The authorization shall accompany any care
						  recipient's medical records to the department. The authorization must:
(1) be in writing
(2) be in 14-point typeface or
						  larger
(3) be clearly separate from
						  any other language present on the same page
(4) state the name of the claimant and
						  identify him or her as the care provider
(5) state the name of the physician or
						  practitioner who is authorized to disclose the care recipient's medical
						  information and identify that individual as the care recipient's treating
						  physician or practitioner
(6) state
						  that the care recipient authorizes his or her physician or practitioner to
						  disclose his or her medical information to the care provider, the care
						  provider's voluntary plan as the term is used in Chapter 6, Part 2, Division 1,
						  of the code commencing with section
						  3251 et seq., and the Employment
						  Development Department
(7) state
						  that the care recipient authorizes the disclosure solely to support the care
						  provider's claim for Family Temporary Disability Insurance benefits
(8) state that the physician or practitioner
						  may disclose
(A) the care recipient's
						  diagnosis
(B) the care recipient's
						  International Classification of Diseases code or, where no diagnosis has yet
						  been obtained, a detailed statement of symptoms
(C) a statement setting forth the facts of
						  the care recipient's serious health condition that warrants the participation
						  of the care provider
(D) the date
						  on which the condition commenced
(E) probable duration of the
						  condition
(F) estimated amount of
						  time each day the physician or practitioner believes that the care provider is
						  needed to care for the care recipient
(9) state that the authorization is valid for
						  10 years from the date the voluntary plan receives it or the effective date of
						  the claim, whichever is first
(10)
						  state that the care recipient may request a copy of the authorization from the
						  voluntary plan by writing to it at a specified address
(11) state that the care recipient may revoke
						  the authorization by writing to the specified address
(12) state that the medical information may
						  be used by the voluntary plan or the Employment Development Department to
						  determine the care provider's eligibility for Family Temporary Disability
						  Insurance benefits
(13) include a
						  signature and date line for the care recipient
(14) instruct authorized representatives, as
						  defined in section
						  3302-1(a), to
						  sign on behalf of the care recipient and indicate the source of authority to
						  act for the care recipient.