Can I Get Short-Term Disability Benefits for Elective Surgery?
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I have to have an operation to correct two slipped discs in my back and a hernia. I won’t be able to work for a while after the surgery and my family is dependent upon my income. Is there a way to get short-term disability benefits?
Short-term disability insurance (SDI) benefits provide income protection for individuals who become medically unable to work for a brief period of time, from as short as a week up to six months. (The benefits we're discussing are provided by a private insurer -- there is also state-provided short-term disability.)
These SDI benefits are available only after all of your sick leave is exhausted, and they usually terminate when a person returns to work or is approved for long-term disability. Private SDI benefits typically pay from 60% to 70% of your former salary, though the details in your case will depend on the specifics of your plan.
SDI covers accidents and illnesses that prevent people from working, and this includes most, but not all, surgical procedures. Generally SDI benefits are payable for surgeries as long as they are "medically necessary."
When Is a Procedure Medically Necessary?
The precise definition of a "medically necessary" procedure will be spelled out in your SDI plan documents. Often it will look require that the procedure is both:
- prescribed by a doctor as a required treatment of your injury or illness, and
- appropriate according to generally accepted standards of medical practice in the place where the surgery is performed.
If you're wishing to apply for SDI benefits due to an operation and you're wondering whether it will be covered by SDI, ask your surgeon whether he or she will certify that your procedure is necessary and appropriate for your condition. Then obtain a written statement from your doctor regarding the nature and extent of your condition and an explanation of why surgery is appropriate. Your doctor should also address your potential recovery period and any restrictions you will be under during that time. If your doctor won't help you, find one who will. Your insurer will evaluate the opinion evidence from your doctor along with your recent medical records in deciding your case.
SDI plans usually require less evidence of disability than long term plans, because they only pay benefits for a very limited time. Still, your medical records and your doctor's opinion must be sufficient to persuade your insurer of the medical necessity of your operation, or your claim may be denied.
What Types of Procedures Are Considered Medically Necessary?
Emergency surgery. If you've undergone an emergency or life-saving surgery, such as a cardiac bypass following a heart attack, time off for your surgery and a reasonable recovery period will certainly be covered by your SDI insurance.
Elective surgery. Most surgeries are not emergency but elective, meaning they are planned in advance. The aim of elective surgeries is generally to improve the quality of one's life rather than to prolong life, though some elective surgeries (like angioplasties) try to do both.
Elective surgeries that are not covered. There are some types of elective surgeries that will almost never be covered by your SDI plan. Time off for cosmetic surgeries like nose jobs, face lifts, and breast augmentation surgeries won't be included in your SDI plan. Dental surgery is usually not covered, except perhaps if it is a result of an accident or injury. If your surgery is the result of a self-inflicted injury, suicide attempt, or felony, you will also likely be denied SDI benefits.
Reconstructive surgeries. In most instances, medical leave for plastic surgery will be covered by SDI as long as it is designed to improve the function (rather than merely the appearance) of a body part. Some examples include reconstructive surgery following a burn, craniofascial surgery to treat a cleft palate, and facial reconstruction surgery following cancer.
Weight-loss surgery. Leave for bariatric (weight-loss) surgery is routinely covered by SDI plans, but check with your human resources department and consult your disability insurance policy to be sure.
Pregnancy and childbirth. One often overlooked situation where SDI benefits may be available is during pregnancy and following childbirth. Note that many policies consider pregnancy to be a pre-existing condition, however, meaning pregnancy and childbirth won't be covered within nine months of the date your coverage becomes effective.
When a Procedure Is Not Medically Necessary
There is at least one situation where you can undergo a surgery that is not "medically necessary" and still receive SDI payments, and that is where you donate an organ. As long as the organ transplant procedure is non-experimental, you can almost always still be approved for short-term disability.