7.2 Adjudication

7.2 Adjudication

Adjudication is the insurance process where a determination is made regarding the individuals eligibility for benefits. Based on the organization’s insurance policy, the adjudicator evaluates the client’s medical evidence and makes a decision regarding the eligibility for such benefits as long term disability benefits. There are typically three types of disability/sick benefits in many organizations:

• Sick Leave: usually this is a few days or weeks in length. Usually, no adjudication takes place; rather a doctor’s note is provided to the supervisor/HR department.

• Short Term Disability – this benefit typically begins when sick leave runs out. Most short term disability plans pay a percentage of the individual’s wages (e.g. 70%) and runs for a defined period of time (e.g. 15, 26 or 52 weeks). There is often an adjudicator involved in this process.

• Long Term Disability – This benefit begins when short term disability benefits end. Typically, long term disability is paid for two years at which time a determination is made regarding the individual’s ability to return to work. Some policies end at this time if the individual can return to “any job”. Other policies allow benefits to continue if the individual cannot return to their “own job”.