Short-Term Disability Benefits for Medical Operations

Short-term disability insurance (SDI) benefits provide income protection if you become medically unable to work for a brief time, from as short as a week up to six months or a year. SDI benefits are generally available only after you've used all your sick leave. And SDI benefits end when you return to work or are approved for long-term disability.

Short-term disability benefits (also known as temporary disability benefits, or TDI, in some states) cover accidents and illnesses that prevent you from working, including the time you take off when you need a medical operation or procedure. Generally, SDI and TDI benefits are payable for surgeries considered "medically necessary"—including some elective surgeries.

If you expect to take time off for a medical operation or procedure, SDI can ensure you have income while you can't work—but only if the procedure is covered. Here's what you need to know about how short-term disability works for surgery and other medical procedures.

Types of Short-Term Disability Insurance Programs

There are a few ways you can get short-term disability insurance. You might get SDI benefits through your employer or from a state program. Or you might buy a private policy.

State-mandated SDI Coverage: A handful of states have laws in place that give employees the right to short-term disability coverage, including:

• California
• Hawaii
• New Jersey
• New York, or
• Rhode Island.

Some states provide SDI coverage through a state fund, typically paid for by employee contributions, employer contributions, or both. Other states simply require that employers provide this insurance. If you work in one of these states, contact your human resources department or state labor department for information about your coverage.

Employer-sponsored short-term disability: Many employers offer short-term disability coverage through a long-term disability company as an employee benefit, voluntarily. Your employer-sponsored SDI might be paid fully by your employer, or you might have to contribute from payroll withholding. Your human resources department can provide information on your employer-sponsored plan.

Private short-term disability insurance: You might have purchased your own short-term disability insurance from a private insurer. In this case, contact your insurance carrier for information on your coverage details.

Learn more about how to get short-term disability insurance.

When Is Surgery Covered by Short-Term Disability Insurance?

What a particular SDI policy covers and excludes will be determined by the plan's terms. Typically, a short-term disability plan provides some wage replacement (a percentage of your salary) while you're temporarily unable to work due to an illness or injury suffered off the job.

The terms of your plan (or state law) will determine which conditions your SDI covers. Some plans cover elective procedures, like cosmetic surgery or gastric bypass surgery, and others don't. For example, California's state law explicitly provides that elective procedures and cosmetic surgeries are covered (see edd.ca.gov).

But many plans don't cover elective surgery. And some policies won't cover surgery for a pre-existing condition until you've been insured for a certain period of time.

The key for employer-sponsored plans is that your surgery must be medically necessary.

When Is a Surgical Procedure Medically Necessary?

The precise definition of a "medically necessary" procedure will be spelled out in your SDI plan documents. Often it will require that the medical operation 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.

Common examples of medical operations that might qualify you for short-term disability benefits include:

• open heart surgery
• cesarean section (C-section) birth
• removal of your gallbladder or other internal organs
• surgery related to broken bones, and
• knee or hip replacement surgery.

If you plan to apply for SDI benefits to cover your time off for an operation, ask your surgeon to certify that your procedure is necessary and appropriate for your condition. Then ask your doctor for a written statement that explains the following:

• the nature and extent of your condition
• why surgery is appropriate
• your anticipated recovery period, and
• any restrictions you'll be under during recovery.

If your doctor won't help you, find one who will. Your insurer will want to see your doctor's opinion and your recent medical records before 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 that your surgery is medically necessary, or your claim could be denied.

What Types of Medical Operations Are Considered Medically Necessary?

If you must undergo a medical procedure or have surgery, knowing what falls under your insurer's definition of "medically necessary" and what doesn't is essential.

Emergency surgery: If you've undergone an emergency or life-saving surgery, such as a cardiac bypass following a heart attack, your SDI insurance will undoubtedly cover time off for your surgery and a reasonable recovery period.

Elective surgeries that are probably covered: Most surgeries aren't emergencies and are considered elective—meaning they're planned in advance. The aim of elective surgeries is generally to improve your quality of life rather than to prolong your life, although some elective surgeries (like angioplasties) try to do both.

Elective surgeries that aren't covered: There are some types of elective surgeries that short-term disability insurance plans rarely cover. Your SDI plan probably doesn't cover time off for cosmetic surgeries like:

• nose jobs
• facelifts, and
• breast augmentation surgeries.

Dental surgery is also not usually covered, except perhaps, if it results from an accident or injury.

Other medical operations that aren't covered: You'll likely be denied SDI benefits if your surgery is the result of any of the following:

• self-inflicted injury
• attempted suicide, or
• commission of a felony.

Reconstructive surgeries: In most instances, medical leave for plastic surgery will be covered by SDI as long as it's designed to improve a body part's function (rather than merely the appearance). Some examples include:

• reconstructive surgery following a burn
• craniofacial surgery to treat a cleft palate, and
• facial reconstruction surgery following cancer.

Gastric bypass surgery: Gastric bypass or bariatric (weight loss) surgery is used to treat morbid obesity, defined as a body mass index (BMI) of 40 or more. It's generally not performed unless the patient has already tried and failed to lose weight using other means. You can usually get short-term disability benefits for gastric bypass, but check your SDI policy to be sure.

Pregnancy and childbirth: One often overlooked situation where SDI benefits might be available is during pregnancy and following childbirth. Note that many policies consider pregnancy a pre-existing condition—meaning pregnancy and childbirth generally won't be covered for the first nine months you have the short-term disability insurance policy.

Orgran donation: There's at least one situation where you can receive short-term disability benefits for a surgery that isn't medically necessary: when you donate an organ. As long as the organ transplant procedure is non-experimental, you'll almost always be approved for short-term disability benefits.

How Does Getting Short-Term Disability Benefits for Surgery Work?

Contact your human resources department or your insurance carrier as soon as you know you need surgery. You'll generally need to complete and submit a claim form. You also need to have your doctor and your employer complete their parts of the form.

Many policies impose a waiting period—usually seven days for state plans and up to two weeks for employer or private policies. So you probably won't receive benefits for all the time you're off work.

How much money you get, how long benefits last, and other details will all be determined by the terms of your policy. Most plans will cover about 60% of your previous salary for three to six months. Some state SDI plans pay benefits for longer; for instance, you can get California SDI for up to a year.

Hiring a Disability Attorney for Your SDI Claim

If you believe you were wrongly denied coverage for a medical procedure under a short-term disability plan, you might want to consult with a disability lawyer. A lawyer can review the plan and help you determine whether your medical procedure or operation should have been covered. And if you decide to appeal the denial, your lawyer can assist with that as well.