Disability Claims Procedure

Section 1600.550  Disability Claims Procedure a)         Pursuant to Code Section 15-150, a participant may be granted a disability benefit if, while a participating employee, he or she becomes physically or mentally incapacitated and unable to perform the duties of his or her assigned position for any period exceeding 60 consecutive calendar days and the employee had completed 2 years of service at the time of disability, unless the disability is a result of an accident or the employee is a police officer who qualifies for line-of-duty disability benefits under Section 15-153(b) of the Code . An employee shall be considered disabled only during the period for which the Board determines, based upon the evidence listed in this Section, that the employee is unable to reasonably perform the duties of his or her assigned position as a result of a physical or mental disability. This determination shall be based upon: 1)         a written certificate from one or more licensed and practicing physicians appointed by or acceptable to the Board, stating that the employee is disabled and unable to reasonably perform the duties of his or her assigned position; 2)         a written certificate from the employer stating that the employee is unable to perform the duties of his or her assigned position and, if the employee is a police officer applying for a line-of-duty disability, the employer's position on whether the disability qualifies as a line-of-duty disability ; and 3)         any other medical examinations, hospital records, laboratory results, or other information necessary for determining the employment capacity and condition of the employee; and 4)         if the employee is a police officer applying for a line-of-duty disability, a written certification from one or more licensed and practicing physicians appointed by or acceptable to the Board, stating that the disability qualifies as a line-of-duty disability under Section 15-153(b) of the Code. b)         Application Filing Requirements 1)         An application for disability benefits must include the certifications described in subsections (a)(1), (a)(2), (a)(4), if applicable, and supporting documentation described in subsection (a)(3), all as explained in more detail in this Section, for each disabling condition as well as for the entire period of disability. 2)         The application must be filed within one calendar year after the date on which the disability occurred. The application is deemed to have been filed on the date on which the System first receives any part or section of the application. This limitation may be waived upon a showing of good cause, including, but not limited to, extenuating circumstances in which the applicant was under significant physical, mental or medical infirmity or legal status that prevented the applicant from filing within the time period. c)         Certification By Physicians.  For purposes of subsections (a)(1) and (a)(4), the following shall apply: 1)         Physicians acceptable to the Board are attending physicians, physicians designated by the participant and physicians to whom the participant was referred by the attending or designated physician.  Physicians appointed by SURS staff to examine the participant are deemed to be physicians appointed by the Board.  The physician must be licensed to practice and be currently practicing in the field of expertise related to the underlying physical or mental condition for which disability benefits are sought. 2)         The certification must be signed by a physician described in subsection (c)(1) or an authorized representative of the physician and must state the following: A)        the medical diagnosis of the physical or mental condition; B)        the prognosis of the physical or mental condition; C)        the physical or mental limitations to which the participant should adhere; and D)        that the participant is disabled and is unable to reasonably perform the duties of his or her assigned position as a result of the physical or mental disability; and E)        if the employee is a police officer applying for a line-of-duty disability, that the disability qualifies as a line-of-duty disability under Section 15-153(b) of the Code. 3)         The certification must be accompanied by a report containing the following: A)        the date of examination; B)        the medical history of the participant; C)        the results of any diagnostic tests used; D)        the diagnosis of the physical or mental condition; E)        the plan of treatment for the physical or mental condition and prognosis in response to the treatment plan; F)         an evaluation of the physical or mental condition as it bears upon the participant's ability to reasonably perform the duties of his or her assigned position; and G)        any existing documentation of objective medically demonstrable anatomical, physiological or psychological abnormalities manifested as test results or laboratory findings apart from self-reported symptoms. d)        Certification by Employers.  For purposes of subsection (a)(2), the certification must be signed by an officer authorized by the employer and must state the following: 1)         the physical or mental performance requirements for the reasonable performance of the participant's assigned position; 2)         whether the participant is able to satisfy each physical or mental performance requirement for the reasonable performance of his or her assigned position to the best of the employer's knowledge or belief and the reason for that knowledge or belief; 3)         whether the participant is able to reasonably perform the duties of his or her assigned position based on the provisions of subsections (d)(1) and (d)(2); and 4) if the employee is a police officer applying for a line-of-duty disability, the employer's position on whether the disability qualifies as a line-of-duty disability under Section 15-153(b) of the Code. e)        Determination of Regular and Line-of-Duty Disability.  If the participant establishes, by a preponderance of the evidence, that he or she is physically or mentally disabled and unable to perform the duties of his or her assigned position as a result of the disability, the participant shall be determined eligible for regular disability benefits under Section 15-153(a) of the Code. In lieu of regular disability benefits under Section 15-153(a) of the Code, if a police officer establishes, by a preponderance of the evidence, that as the result of sickness, accident, or injury incurred in or resulting from the performance of an act of duty, the police officer is found to be physically or mentally disabled for employment as a police officer so as to render necessary his or her suspension or retirement from employment as a police officer or is found to be unable to perform his or her duties as a police officer by reason of heart disease, stroke, tuberculosis, or any disease of the lungs or respiratory tract, resulting from employment as a police officer , the police officer shall be determined eligible for line-of-duty disability benefits under Section 15-153(b) of the Code. Any police officer who suffers a heart attack or stroke as a result of the performance and discharge of police duty shall be considered to have been injured in the performance of an act of duty and shall be eligible for line-of-duty disability benefits under Section 15-153(b) of the Code.  For purposes of Section 15-153(b) of the Code, a police officer shall be considered to be in the performance of an act of duty while on any assignment approved by the police officer's chief, whether the assignment is on or off the employer's property. [40 ILCS 5/15-153(b)]. 1)         SURS staff shall determine whether certifications made under subsections (a)(1), (a)(2), and (a)(4), if applicable, and supporting documentation described in subsection (a)(3) establish eligibility for regular disability benefits or line-of-duty disability benefits. 2)         At the discretion of SURS staff, the participant may be required to submit to additional examinations by staff appointed physicians or specialists to aid in the determination process. 3)         Physical or mental conditions resulting from self-inflicted injuries, substance abuse, or any act for which the participant was convicted of a misdemeanor or felony A)        are not the result of an accident for purposes of Section 15-150 of the Code; and B)        are not a sickness, accident, or injury incurred in or resulting from the performance of an act or duty for purposes of Section 15-153(b) of the Code . f)         Subsequent Re-examination of Disabled Participants 1)         SURS staff shall secure from one or more physicians, periodically, re-evaluation reports concerning the continued disability of the participant.  The date of re-evaluation shall be determined by SURS staff on the basis of the medical reports received previously, the nature of the disability, and other relevant information. 2)         In the re-evaluation of disability claims, the examining physician shall be the attending physician or the physician designated by the participant, but, if the nature of the disability or other circumstances justifies the appointment of someone other than the participant's attending physician or designated physician as the examining physician, SURS staff shall make the appointment.  All other procedures that may be applicable in processing the initial claim for disability benefits shall be followed in re-evaluation of the claim. g)         Release of Medical Information.  The participant may be required to authorize the release of all medical or other information related to the disability claim, including but not limited to medical reports, hospital records, Department of Employment Security earnings statements, income tax records, unemployment records, and any record deemed necessary to the administration of the disability claim.  The failure of the participant to submit to a re-evaluation examination or a treatment plan, to produce records, or to approve release of information required shall result in the discontinuance of disability benefit payments under Section 15-152 of the Code or suspension under Section 1600.160 of this Part, as applicable . h)         Vacation Payments and Disability Benefit Commencement.  If an employee receives payment for unused vacation leave accrued under the employment from which the employee is disabled, the date of the "termination of payment of salary or sick leave benefits" under Section 15-151 of the Code shall be delayed by the number of work days attributable to the vacation payment.