§ 5.27.410. Claims.

A.

Application for Benefits. The Eligible Participant shall give notice of the Disability to the Claims Administrator in accordance with the procedures established for such purpose in the Election Information.

B.

Evidence of Disability. Written medical certification of Disability must be submitted by a Physician, practicing within the scope of his license, to the Claims Administrator within the time frame established for such purpose in the Election Information. Failure to furnish Evidence of Disability within the time required will not invalidate or reduce any claim if it was not reasonably possible to give such evidence within such time, provided that the Evidence of Disability is furnished as soon as reasonably possible.

C.

Medical Records and Medical Examination. The Claims Administrator may require such additional evidence, as is deemed necessary, including copies of medical records, and/or a medical examination at County expense to determine the existence, cause and extent of any injury or illness which may be the basis of a claim under the STD Plan.

D.

Determination.

1.

If the Evidence of Disability shows to the satisfaction of the Claims Administrator that an Eligible Participant is Disabled, the STD Plan benefit as specified under this section shall become payable effective as of the expiration of the Waiting Period.

2.

If the Claims Administrator determines after review of the Evidence of Disability and all other evidence, including, but not limited to, medical records and medical examination, that an Eligible Participant is not Disabled, no benefits under this STD Plan shall be payable.

E.

Appeal. A Participant may appeal any denial, cessation, or cancellation of benefits under the STD Plan by filing a written notice of appeal with the Claims Administrator, together with any pertinent supporting medical documentation. The Claims Administrator shall conduct a full and fair evaluation of the appeal and render a decision, which shall be final. The appeal from the Participant, and the final decision from the Claims Administrator shall be completed within the time frames established for such purposes in the Election Information. If the employee's disability precludes submission of medical documentation within the established time frames, the deadline for the appeal may be extended by the CEO or his designee. Consideration of such extension by the CEO is contingent upon the provision of the medical documents as soon as reasonably possible.

(Ord. 2014-0033 § 4, 2014; Ord. 90-0164 § 1 (part), 1990.)