What Qualifies for Short-Term Disability?

When employees cannot work due to non-work-related injuries, illness, or pregnancy-related complications, South Carolina short-term disability benefits can provide financial assistance. A short-term disability is defined as an illness or procedure that temporarily necessitates time off of work.

Generally, an employer provides short-term disability benefits as part of their employee benefits package. It is also possible to purchase a policy separately. However, what qualifies for short-term disability is not always clear.

To qualify for short-term disability benefits, you must have short-term disability insurance coverage. You may be eligible for benefits if you suffer a non-work injury, become ill, or cannot work due to other covered reasons.

This blog post will cover the basics of getting short-term disability in SC. In it, weโ€™ll address common questions employees have about short-term disability, including:

  • Does short-term disability cover paternity leave?
  • What is considered a short-term disability?
  • What illness qualifies for short-term disability?

Keep in mind that every insurance policy is different. If you have specific questions about what qualifies for short-term disability, itโ€™s best to consult with a legal professional.

Key Takeaways:

  1. Eligibility. Short-term disability benefits are for non-work-related injuries, illnesses, or pregnancy-related complications. They are often part of an employers benefits package but can also be purchased separately.
  2. Qualifying conditions. Conditions that qualify include accident-related injuries (off-the-job), chronic illnesses, acute diseases, and pregnancy or maternity leave. The condition must be severe enough to prevent work for a limited period and require a doctor's care.
  3. Accident-related Injuries. Injuries from accidents like car accidents or falls that occur off-the-job are covered. This includes injuries requiring medically necessary surgery.
  4. Chronic illnesses. Many chronic diseases qualify for short-term disability, including cancer, asthma, and high blood pressure. COVID-19-related issues are covered if they require medical care, but quarantine without medical care is not.
  5. Acute diseases. Diseases that are severe and likely to cause a total loss of income, such as pneumonia, heart attack, and appendicitis, qualify.
  6. Pregnancy and maternity leave. Short-term disability typically covers 6-8 weeks following childbirth for maternity leave and can include complications before birth and recovery from labor and delivery.
  7. Eligibility and benefits. Check with your employer for coverage details. Benefits usually start after a waiting period and provide a percentage of regular salary, typically 60-70%, for up to 26 weeks.
  8. Denied claims. If a claim is denied or there are issues with the insurance company, consulting with an attorney focusing on specializing in disability insurance is recommended.

What Constitutes Short-Term Disability?

short term disability in South Carolina

To meet short-term disability qualifications, a qualifying medical condition must not be related to the work environment or job-related responsibilities, must be severe enough to prevent the employee from working for a limited period, and must require a doctorโ€™s care. Short-term disability generally covers:

  • Accident-related injuries,
  • Chronic illnesses, 
  • Acute diseases, and
  • Pregnancy or maternity leave.

If the loss of income starts after your policyโ€™s effective date but the medical event occurs while the policy is in force, you might be entitled to benefits for the above conditions (provided that the policy does not explicitly exclude the condition).

What Illness Qualifies for Short-Term Disability?

Short-term disability insurance covers medical conditions that temporarily prevent an employee from working. For an employee to qualify for benefits, the condition must meet certain criteria: it should not be work-related (as workersโ€™ compensation would cover those), and it must be severe enough to prevent the employee from performing their job duties for a limited period. The condition must also require medical care, as documented by a physician.

Pregnancy and Maternity Leave

Pregnancy is a significant factor in short-term disability claims in South Carolina. Under state law, pregnancy is considered a temporary disability, and employers must provide accommodations similar to those for other disabilities. Short-term disability policies typically cover six to eight weeks of leave following childbirth. They may extend coverage if complications arise, such as the need for bed rest before delivery or recovery from a C-section.

Chronic Illnesses

Chronic conditions can qualify for short-term disability if they require time off for treatment or recovery. In South Carolina, employees suffering from conditions like cancer, epilepsy, asthma, or high blood pressure may be eligible for benefits if these conditions prevent them from working for a temporary period. Additional chronic conditions that may qualify include:

  • Fibromyalgia,
  • Crohnโ€™s disease,
  • Lupus,
  • Rheumatoid arthritis, and
  • Chronic respiratory issues like chronic obstructive pulmonary disease (COPD) or cystic fibrosis.

Acute Diseases and Injuries

Short-term disability insurance generally covers acute diseases. These illnesses include:

  • Pneumonia,ย 
  • Strokes,
  • Heart attacks, andย 
  • Appendicitis.

Acute diseases often require immediate medical attention and significant recovery time, making employees eligible for short-term disability benefits. 

COVID-19 and Related Conditions

The COVID-19 pandemic has prompted some changes to short-term disability coverage. While South Carolina employees may qualify for short-term disability benefits if they experience severe COVID-19 symptoms requiring medical care (such as respiratory issues or high fevers), quarantine without medical care typically does not qualify for benefits. This distinction underscores the importance of medical documentation in filing successful claims.

What Else Does Short-Term Disability Cover?

Letโ€™s take a closer look at some examples of short-term disability-eligible conditions.

Accident-Related Injuries

Whether you have a car accident or accidentally trip when walking downstairs, your policy should cover the short-term disability if the injury occurred off-the-job. Common injuries related to accidents could include: 

  • Broken bones,
  • Burns,
  • Head trauma,
  • Concussions, and
  • Muscle or spine injuries.

Short-term disability also covers the period following a medically necessary surgery related to the injuries.

If the injuries resulted specifically from a car accident, remember that your auto insurance might cover hospital bills and lost wages. Your policy might coordinate benefits and limit your short-term disability coverage. Be sure to check the language of your policy to be sure.

Does Short-Term Disability Cover Paternity Leave?

Pregnant employees will likely be eligible for short-term disability benefits for six to eight weeks following childbirth for maternity leave. Working mothers can also file claims for medical complications of pregnancy before birth, recovery from labor and delivery, and postpartum health disorders (other than depression).

Generally, short-term disability does not cover paternity leave, because a father is not under a doctorโ€™s care. However, new fathers may be able to receive unpaid paternity leave under the federal Family and Medical Leave Act (FMLA).

What Conditions Are Excluded from Short-Term Disability Coverage?

What qualifies for short-term disability can vary from plan to plan. However, certain conditions and situations are typically excluded from short-term disability coverage. These include:

  • Pre-existing conditionsโ€”injuries or illnesses you had before purchasing the policy;
  • On-the-job injuriesโ€”since work-related illnesses and injuries are generally covered by workersโ€™ compensation, short-term disability often wonโ€™t cover them;
  • Elective surgeriesโ€”medical procedures that arenโ€™t necessary for your health or safety, such as cosmetic surgery;
  • Substance abuse disordersโ€”many short-term disability policies wonโ€™t cover conditions related to drug or alcohol abuse unless theyโ€™re receiving treatment from a doctor;
  • Self-inflicted harmโ€”injuries that you purposefully inflict on yourself are typically disqualified from disability benefits; 
  • War or criminal activitiesโ€”harm someone experiences during war or participation in illegal acts generally also falls outside of short-term disability coverage; and
  • Mental health conditionsโ€”certain short-term policies may not cover purely psychological conditions, although this can vary depending on the insurer. 

The specifics around what conditions are excluded and when can vary between plans. Itโ€™s just as important to ensure you understand what situations are excluded from your short-term disability coverage as those that are included. 

How Do Work-Related Factors Impact Short-Term Disability Eligibility

The nature of your employment and how your short-term disability insurance is structured will affect your eligibility for benefits. Employer-sponsored plans often have a waiting period before benefits kick in. Employees may need to use accrued sick leave or vacation time to cover their absence during this time.

Eligibility for self-employed individuals or those who have purchased their own short-term disability policies depends on the terms outlined in their contracts. Self-pay policies often have higher premiums but may provide more flexible coverage options.

Who Qualifies for Short-Term Disability?

Short-term disability aims to provide financial support for employees who canโ€™t work due to a temporary medical condition. The employee must suffer from a qualifying injury or illness to be eligible for benefits. Short-term disability doesnโ€™t apply to the medical condition of a spouse or dependents.

To determine eligibility, check to see if you have any disability coverage through your employer. If you can apply for disability benefits through your employer, you should be sure to apply for those benefits before you stop working to avoid any qualification issues. 

However, even if you have already stopped working, you should check to see if you might be eligible for short-term disability benefits through your former employer. If your former employer did not notify you of potential eligibility for these benefits before the application period lapsed, you could still be eligible to go back and apply.

If you believe you were wrongly denied short-term disability benefits, contact an attorney for guidance.

What South Carolina-Specific Regulations and Requirements Should I Be Aware Of?

South Carolina does not offer a state-run short-term disability program, meaning employees must rely on employer-sponsored plans or private insurance policies. Employers are not legally required to provide short-term disability insurance, but many offer it as part of their employee benefits package. Each employer-sponsored plan may have different eligibility criteria, waiting periods, and coverage levels, making it essential for employees to understand the specific terms of their policies.

In South Carolina, FMLA often works in conjunction with short-term disability benefits, especially for medical issues that extend beyond the disability coverage period. The FMLA guarantees job protection for up to 12 weeks of unpaid leave for qualifying medical or family reasons, although it does not provide income replacement.

What Should I Know About Policy-Specific Exclusions and Limitations?

South Carolina employees should be aware of any exclusions in their short-term disability policies. Common exclusions include:

  • Pre-existing conditions (if not disclosed before purchasing the policy),ย 
  • Injuries resulting from self-harm or illegal activities, and
  • Work-related injuries.

Understanding these exclusions is necessary to avoid denied claims and ensure you receive the benefits you're entitled to.

What Benefits Does Short-Term Disability Offer?

The amount of short-term disability benefits an employee can receive in South Carolina will vary depending on the policy. Generally, employees can expect a percentage of their regular salary while they cannot work. This amount is typically around 60 to 70% of their regular pay.

Common uses for short-term disability benefits are:

  • Rent or mortgage payments,
  • Medical expenses,
  • Childcare,
  • Utility bills,
  • Groceries and personal care items,
  • Car and gas payments,
  • Insurance premiums, and
  • Other basic living expenses.

Since short-term disability benefits are intended to replace lost income, employees are generally free to use them however they wish. However, individual insurance policies may have different requirements for what these benefits can fund. Review your policy details to understand the limits of whatโ€™s eligible.

How Do I Apply for Short-Term Disability?

To apply for benefits after an injury or illness, you must file a claim with your short-term disability insurance provider. 

In some cases, an employee may be able to file a claim directly with the insurer. In others, you may have to go through your employer to apply. In either case, itโ€™s important to notify your employer about your plans to file for benefits sooner rather than later. For one, itโ€™s good to keep your boss informed whenever you have a condition that prevents you from working.

Additionally, communicating with your employer about your plans can help ensure adequate preparation for the application process. Meeting with someone from your HR department before filing your claim can shed light on important details about coverage, exclusions, and other benefit details. 

When you file a short-term disability claim, youโ€™ll be asked to provide information about your condition and how it prevents you from working. Be prepared to describe:

  • Your typical job responsibilities,
  • The cause of your injury or illness,
  • How your symptoms started,
  • When you last worked,
  • When you expect to return to work,
  • Medical treatment youโ€™ve received for your condition so far, and
  • Contact information for doctors whoโ€™ve treated you.

Generally, short-term disability applications also require medical documentation of your condition. This documentation could include records from recent treatment, copies of prescriptions, or a statement from your doctor verifying the details of your condition.

Applying for benefits before stopping work is crucial to avoid delays or disqualification. If youโ€™ve already stopped working, consult your employer or insurance provider to determine if you can still file a claim.

What Happens When I Get Short-Term Disability?

In South Carolina, short-term disability benefits typically begin after a waiting period of around 7-14 days, depending on your policy. During this time, the employee must use their sick leave or vacation time to cover your absence from work. Once the waiting period ends, an employee can receive their benefits.

The amount of short-term disability benefits an employee can receive in South Carolina will vary depending on the policy. Generally, employees can expect a percentage of their regular salary while they cannot work. This amount is typically around 60 to 70% of their regular pay.

Short-term disabilities are typically provided for a period of up to 26 weeks. However, the exact duration of benefits will depend on the terms of their policy. In some cases, employees may be able to extend their short-term disability benefits if their condition requires additional time off work.ย If your condition extends beyond the maximum coverage period, you may need to transition to long-term disability insurance.

What Is the Difference Between Short-Term Disability and Workersโ€™ Compensation?

Short-term disability benefits and workersโ€™ compensation benefits both provide financial support to employees who canโ€™t work due to illness or injury. However, the two programs are different in several important ways.

First, all South Carolina employers with more than four employees are required by law to carry workersโ€™ compensation insurance. The same isnโ€™t true for short-term disability insurance, which is an optional benefit employees or employers purchase through private insurers. 

Unlike short-term disability benefits, workersโ€™ compensation benefits only apply to employees hurt or made sick on the job. Workersโ€™ compensation also only covers specific, limited benefits, like lost wages, medical bills, and vocational rehabilitation. By contrast, you can use the payments you get through short-term disability as you wish. 

The coverage period for benefits is also different for each program. Short-term disability benefits are generally only available for six months. Workersโ€™ compensation benefits can extend for a longer period of time, depending on the severity of the injury and how long it takes the employee to return to work.

Why Was My Short-Term Disability Claim Denied?

Even if you have a qualifying condition, thereโ€™s no guarantee that your claim for short-term disability benefits will be approved. Itโ€™s in the best interest of your insurance company to pay out the lowest amount of benefits possibleโ€”or none at all.

Here are some common reasons that your short-term disability claim might be denied:

  • Insufficient medical evidence. This is one of the most common reasons insurers reject short-term disability claims. Detailed documentation from a credible medical source is a must when filing for disability benefits. 
  • Lack of disability. Each insurance policy has specific criteria an employee must meet to be considered โ€œdisabled,โ€ even temporarily. If your condition isnโ€™t sufficiently debilitating to completely prevent you from working, your claim might be denied.
  • Policy exclusions. Each short-term disability policy lists situations it does and doesnโ€™t cover. Failing to review the terms and conditions of your policy closely can result in a prompt rejection.
  • Missing or incomplete information. Employees must provide many different types of information and documentation in a short-term disability application. Overlooked errors, typos, or questions can send an application directly to the rejection pile. 
  • Failure to follow treatment. Evidence that you disregarded or ignored a doctorโ€™s recommendations during your treatment can also be bad news for your application. When this happens because you fail to follow medical advice, it can lead to a denial.
  • Late filing. Some plans put time limits on when you can file a claim after an illness or injury arises. If you wait too long to take action or miss other important deadlines, your claim might not be considered. 
  • Fraudulent claims. Insurers may also deny a claim if they suspect someone isnโ€™t honest about their medical condition. After you file a claim, insurance adjusters will investigate the basis for your injuries and look for evidence that contradicts it, e.g., social media posts, recent activity, and statements from friends and neighbors. 

Unfortunately, many deserving employees have valid disability claims denied at first because of a policyโ€™s fine print or misrepresentation by an insurer. However, employees who have the help of a legal professional often appeal the denial and ultimately receive the benefits they deserve. 

Was Your Short-Term Disability Claim Denied?

If your claim was denied or you believe that your insurance company is acting in bad faith, you may want to consult with an attorney who specializes in disability insurance. John Peace founded the Peace Law Firm in Greenville, South Carolina, in 2002.

His experience as a former insurance company employee gives him a deep and nuanced understanding of insurance-related issues. For over 15 years, he has passionately represented individuals like you. To request a consultation, please call 864-298-0500. 

Rate this Post

1 Star2 Stars3 Stars4 Stars5 Stars
1 votes, average: 5.00 out of 5
Loading...