Table of Contents
- Sick/Personal Leave for Non-Exempt Staff
- Salary Continuation for Exempt Staff and Faculty (Salaried)
- Grandfathered Sick/Personal Leave Bank
- Other Information Regarding Absences
- Short-Term Disability
- General Information
- STD Pay Information
- Defined Terms
- 12 Month Employee and Less Than 12 Month Per Fiscal Year Employee Who is Paid Over 12 Months Per Fiscal Year
- Less Than 12 Months Per Fiscal Year Employee Who is Paid Only During Scheduled Work Time
- Less Than 12 Months Per Fiscal Year Employee Whose Disability Date Occurs When the Employee is Scheduled to Work and Continues Into Unscheduled Work Time
- Less Than 12 Months Per Fiscal Year Employee Whose Disability Date Begins Within 28 Days of Last Day Worked
- Less Than 12 Months Per Fiscal Year Employee Whose Disability Date is Greater than 28 Days From Last Day Worked
- If You Become Disabled Again
- Partial Disability
- Holiday Pay During Disability
- Earning Vacation During Disability
- Supplemental Pay When Employment Ends
- Disability Begins After Termination of Employment from RIT
- Procedures for Disability Claims and Appeals
Continuing your income while you are sick or have a non-work related injury is likely one of your top priorities. It is an RIT priority, too. That's why RIT provides Sick/Personal Leave or Salary Continuation and the Short-Term Disability Plan.
This part of your handbook explains the Sick/Personal Leave and Salary Continuation benefit as well as the Short-term Disability Plan in detail - who can be covered, when you qualify for benefits, and how much the plan pays.
Sick/Personal Leave and Salary Continuation benefits are self-insured by RIT from its general assets. Short-term disability benefits are partially funded through an insured arrangement with Prudential covering the component equal to New York State disability benefits. The remainder is self-insured by RIT through its general assets.
Sick/Personal Leave for Non-Exempt Staff
All regular non-exempt employees (full-time, extended part-time, and part-time) are eligible for paid Sick/Personal Leave upon hire. During the first fiscal year of employment (July 1 ‚Äì June 30), a regular full-time non-exempt employee would receive one (1) Sick/Personal day per month, based on date of hire, up to 9 days per year. The employee would receive one day in the month of hire, provided the employee was hired on or before the 15th of the month. During the first fiscal year of employment, a regular extended part-time or part-time employee would receive pro-rated Sick/Personal Leave based on their standard weekly hours. For all non-exempt employees, Sick/Personal Leave is calculated and tracked in RIT‚Äôs time keeping system in hours, based on the individual‚Äôs standard weekly hours.
After the first year of employment, full-time non-exempt staff are credited with 9 Sick/Personal days on July 1. Sick/Personal Leave for regular extended part-time and regular part-time non-exempt employees is pro-rated. Sick/Personal Leave for all non-exempt employees is calculated based on the employee‚Äôs standard hours per week; therefore, the number of hours of Sick/Personal Leave per fiscal year is the standard hours per week multiplied by a factor of 1.8 (9 days per year divided by 5 day week).
Example 1 (full-time):
Standard weekly hours = 40
Sick/Personal leave = 40 x 1.8 = 72 hours per fiscal year
Example 2 (extended part-time):
Standard weekly hours = 20
Sick/Personal leave = 20 x 1.8 = 36 hours per fiscal year
The fiscal year Sick/Personal Leave hours will be ‚Äúfront loaded‚Äù each July 1st (or upon hire) with the total annual Sick/Personal Leave hours; the balance will decrease as Sick/Personal Leave is used. Employees will be able to view the remaining Sick/Personal Leave through Oracle Employee Self-Service on the online payslip.
- For example, full-time employee works 40 hours a week so receives 72 hours of Sick/Personal Leave as of July 1. If the employee is out Sick on July 25 for eight (8) hours, the Sick/Personal Leave amount will show 64 hours remaining on the next online payslip (72 hours less 8 hours).
Staff Employees Scheduled for Less Than 12 Months Per Fiscal Year
Effective August 1, 2012, sick/personal leave will be pro-rated for new hires and for existing
- For example, an employee hired on or after August 1, 2012 who is scheduled to work 40 hours a week, 44 weeks per year, will have 61.2 hours of Sick/Personal Leave as of each future July 1.
44 weeks / 52 weeks = .85 pro-ration factor
40 x 1.8 = 72 hours x .85 = 61.2 hours
Using Sick/Personal Leave
Employees should use Sick/Personal Leave if they are not at work due to
- their own illness (up to 5 consecutive days)
- a family member‚Äôs illness (up to 5 consecutive days)
- personal appointments (e.g., doctor, dentist, teacher conference, etc.)
- other time as needed (e.g., car breaks down on the way to work, there is a flood in their basement, etc.)
The employee should notify the supervisor as soon as possible that he/she will be absent. If the employee is scheduling a personal appointment, he/she should notify the supervisor in advance.
Cash-Out of Sick/Personal Leave at End of Fiscal Year
A non-exempt employee who does not use all of his or her current allocation of Sick/Personal Leave hours by the end of the fiscal year will receive a cash-out of a portion of the unused Sick/Personal Leave hours (does not include Grandfathered Sick/Personal Leave Bank as described below). The employee can choose to take this cash-out as additional taxable pay, or to have it contributed to the employee‚Äôs retirement savings account. If taken as taxable pay, the cash-out would be one-half (¬Ω) of the employee‚Äôs unused Sick/Personal Leave hours. If contributed to the employee‚Äôs retirement account, the cash-out would be three-quarters (¬æ) of the employee pre-tax unused Sick/Personal Leave.
Example: Mary is full-time and works 8 hours a day for a total of 40 hours per week. She does not use any of her 9 days (72 hours) of Sick/Personal Leave during the current year. She can elect to receive her cash-out as follows:
- ¬Ω remaining Sick/Personal Leave, 36 hours, in taxable pay; or
- ¬æ of remaining Sick/Personal Leave, 54 hours, as pre-tax pay, contributed to RIT‚Äôs Retirement Savings Plan.
In order to qualify to receive that year‚Äôs cash-out, an employee must be employed on June 30th. Employees who retire on June 30 are eligible for the cash-out. An employee who transfers from non-exempt to exempt status during the year will not qualify for a cash-out. In addition, there will not be a cash-out in the event of termination of employment, including retirement, during the year.
Salary Continuation for Exempt Staff and Faculty (Salaried)
Regular exempt staff and faculty employees receive salary continuation instead of Sick/Personal Leave when absent for five (5) consecutive business days or less. Salary continuation is paid at 100% of regular base pay.
Grandfathered Sick/Personal Leave Bank
An employee who was on the RIT payroll and had any unused Sick/Personal Leave as of June 30, 2005 will have a Grandfathered Sick/Personal Leave Bank. This Grandfathered Sick/Personal Leave Bank would be used as outlined below.
- Non-exempt employees could use the Grandfathered Sick/Personal Leave Bank as Sick/Personal Leave if they are absent after they use the current year‚Äôs Sick/Personal Leave.
- Non-exempt and exempt employees would be able to use this Grandfathered Sick/Personal Leave Bank to supplement the 80% short-term disability (STD) benefit if STD is longer than nine (9) weeks such that they would receive 100% of pay.
- Any non-exempt or exempt employee on Workers Compensation for more than nine (9) weeks, could supplement the statutory Workers Compensation benefit by using grandfathered Sick/Personal Leave to receive 100% of pay.
- All non-exempt and exempt employees may use Grandfathered Sick/Personal Leave when taking care of a dependent with a serious health condition when approved under FMLA.
Any grandfathered Sick/Personal Leave must be used ‚Äú1-for-1‚Äù meaning that you will use one day to supplement any portion of a day absent from work. For example, if you are receiving the 80% STD benefit and supplement with the Grandfathered Sick/Personal Leave, you will use one Grandfathered Sick/Personal Leave day for each day you supplement the 80% STD benefit.
Grandfathered Sick/Personal Leave is not cashed out upon termination of employment or retirement and is not reinstated if you are rehired at a later time.
Other Information Regarding Absences
When an employee‚Äôs non-work-related illness or injury extends beyond seven (7) consecutive calendar days, he/she must apply for New York State Disability benefits (refer to short term disability section). When a non-exempt employee who is ill has used all of the annual Sick/Personal Leave, his/her supervisor may classify the absence as excused without pay for a limited period. A pattern of repeated absenteeism may lead to disciplinary action and may be grounds for termination of employment.
Illness in the Immediate Family
Paid time off is provided to employees whose presence is required to care for an ill member of their immediate family. For the purpose of this policy, ‚Äúimmediate family‚Äù is defined as: spouse/domestic partner, child, step-child, ward, mother, mother-in-law, father, father-in-law, brother or sister. A non-exempt employee may use up to 5 consecutive accrued Sick/Personal Leave days per incident. An exempt employee may use up to 5 consecutive Salary Continuation days per incident. Periods of such absence beyond five consecutive working days require the use of vacation time, or may be granted as an unpaid leave of absence. Both the use of vacation time and unpaid leave of absence are subject to the approval of the supervisor in consultation with Human Resources. If the absence exceeds five consecutive working days and the employee qualifies for FMLA for taking care of a family member, the employee may use time in the Grandfathered Sick/Personal bank, if any, after the five consecutive days. An exempt employee can use a maximum of 12 Salary Continuation days per fiscal year to take care of an immediate family member.
Employees who are unable to report to work due to an absence must notify (or have someone else notify, if unable) their immediate supervisor or the department head within a minimum of one hour of their scheduled reporting time. You do not need to give details about your medical condition, just let your supervisor know that you are unable to work.
Prudential, RIT‚Äôs insurance company for short-term and long-term disability benefits, provides FMLA absence reporting and disability management services to RIT and its employees. Therefore, you also must call Prudential‚Äôs toll-free phone number (1-877-908-4778 or log on to www.prudential.com/mybenefits, click on claim submission and follow the instructions) in the following situations.
After reporting your absence for leave or disability to your supervisor, report it to Prudential when:
- You will be absent for more than three days and are under a physician‚Äôs care
- You are hospitalized for any amount of time
- You are caring for an ill or injured FMLA-qualified family member (spouse, parent, or dependent child)
- You are pregnant or are absent from work due to pregnancy complications
- You will be absent periodically due to a chronic or permanent disabling condition of your own or a qualified family member
- You are caring for a newborn child, recently adopted child, or new foster child.
- You are absent due to a lost-time, work-related injury ‚Äì after first reporting it to your supervisor
If your absence is planned in advance, you should contact Prudential 30 days before your absence begins or within 2 days of learning of the need for leave if your absence is to begin within 30 days. This may be the case, for instance, if you are undergoing elective surgery, or for a maternity disability.
You should contact Prudential as soon as possible so there is no delay in receiving short-term disability pay. If you don‚Äôt call Prudential, your pay may be delayed for days you qualify for Short-Term Disability benefits.
If you are unsure whether your absence should be reported to Prudential, please call and the Prudential representative will review your situation and determine what the next steps are.
Information You Will be Asked to Provide When You Call Prudential
- Employer Name
- RIT Control Number - 50757
- Employee ID
- Reason for your Absence
- First day absent
- Work Schedule
- Date of expected return to work if known, or the actual date of return, if you have already returned to work
- If your absence is related to illness or injury, name, fax, and telephone number of the treating physician
- If caring for a qualified family member, their relation to you.
Employees who fail to contact their supervisor will be considered to be on unauthorized leave. If the unauthorized leave continues for three working days, there may be disciplinary action, including termination of employment.
RIT reserves the right in all cases of absence due to illness or injury to have the individual examined by an appointed or approved physician prior to or at the time of return to active employment.
Prudential's Contact Information: 1-877 -908-4778 or www.prudential.com/mybenefits
When you are absent from work because of a non-occupational (non-work related) accident, pregnancy or illness that is not covered by Workers‚Äô Compensation, Short-Term Disability (STD) benefits help protect your income.
Who is Covered and When
All regular full-time, extended part-time, and part-time employees are eligible for the Short-Term Disability Plan as well as Supplemental Pay. If you are a new, regular employee coming to RIT from a New York State Disability covered employer, the Short-Term Disability Plan begins on your first day of employment, including the Supplemental Pay. Otherwise, you must be actively at work for four weeks before you will be covered under the Short-Term Disability Plan and Supplemental Pay.
After four weeks of active employment, non-regular employees, such as Student Workers and adjunct faculty, are covered by the statutory level of New York State Disability benefits. There is no Supplemental Pay for non-regular employees.
Who Pays For Short-Term Disability
RIT pays the entire cost of providing the Short-Term Disability Plan. Benefits are partially funded through an insured arrangement with Prudential covering the component equal to New York State disability benefits. The remainder is self-insured by RIT through its general assets.
Maximum Benefit Period and Job Protection
The duration for STD benefits will not be any greater than a total of 26 weeks in a rolling 52 week period, measured from the Disability Date. RIT holds the position for an employee on an approved short-term disability for 26 weeks. If the employee is not able to return to work within 26 weeks of cumulative lost time in any rolling 52-week period, the department may begin recruitment efforts to fill the position.
Benefit Continuation During Disability
Your other benefits coverage (e.g., medical, dental) continues during periods of short-term disability provided you pay your required employee contributions. The usual payroll contributions for benefits will be taken from your short-term disability benefits to the extent there is sufficient pay to cover them. Otherwise, RIT will either bill you or will deduct the missed deductions when you return to work.
When Coverage Ends
Your Short-Term Disability coverage will end 4 weeks following your last day worked. However, after termination of employment, benefits would be paid at the statutory New York State Disability level, as described in the next section, ‚ÄúSTD Pay Information.‚Äù You would not be eligible for Supplemental Pay.
STD Pay Information
100% Supplemental Pay Period ‚Äì the 8 weeks following the initial one week Waiting Period
80% Supplemental Pay Period ‚Äì up to remaining 18 weeks
Disability - A disability is considered to be any non-work-related illness, pregnancy or injury resulting in an absence greater than seven (7) consecutive calendar days, for which a physician has certified that you are unable to work due to this illness, pregnancy or injury.
Disability Date ‚Äì first date of disability (actual date the employee is certified as disabled including non-scheduled work days); this is the first day of the Waiting Period.
Disability Clock ‚Äì Disability Date through the duration of the disability to a maximum of 27 weeks.
Pay - Pay means base annual pay just prior to the beginning of the disability divided by 52. If an employee is on short term disability when merit increases or market adjustments occur, the increase will take effect on the pay increase date.
Statutory Disability Benefit ‚Äì New York State disability benefits, which is 50% of your Base Pay to a maximum of $170 per week.
Supplemental Pay ‚Äì amount in excess of the Statutory Disability Benefit. If an employee who is scheduled to work less than 12 months a year becomes disabled when they are not scheduled to work, and the Disability Date is greater than 28 days from last day worked, the entire benefit paid would be considered Supplemental Pay.
Waiting Period ‚Äì first seven calendar days beginning on the Disability Date. To be paid during the Waiting Period, a non-exempt employee uses Sick/Personal Leave and/or Grandfather Sick/Personal Bank, if available; if there is not enough Sick/Personal Leave, then the employee can use vacation time, with supervisor approval. If an employee does not have Sick/Personal Leave, Grandfather Sick/Personal Leave, or vacation time, the Waiting Period will be without pay. An exempt employee is eligible for Salary Continuation during the Waiting Period.
It is not necessary to be confined in a hospital to receive benefits from this plan, but you must be under a doctor‚Äôs care. The doctor must provide documentation to Prudential, the insurance company, as requested throughout your disability. Prudential will make a determination on your claim, as described in the Procedures for Disability Claims and Appeals.
After the required Waiting Period, if the insurance company approves STD, eligible employees would be eligible for up to 26 weeks of cumulative STD. The pay during the STD period depends on the employee‚Äôs work schedule; the different schedule and pay scenarios are described below.
12 Month Employee and Less Than 12 Month Per Fiscal Year Employee Who is Paid Over 12 Months Per Fiscal Year
If the insurance company approves STD, regular employees will receive 100% of base pay for up to eight (8) weeks. If you remain disabled, you will then receive 80% of your base pay for up to an additional 18 weeks. STD will continue until the insurance company determines that you are no longer disabled, up to a maximum of 26 weeks.
Less Than 12 Months Per Fiscal Year Employee Who is Paid Only During Scheduled Work Time
If the insurance company approves STD, you are eligible for disability benefits. The STD pay while disabled depends on when the disability begins in relationship to your work schedule:
- Disability Date occurs when you are scheduled to work and continues into unscheduled work time
- Disability Date occurs during unscheduled work time but within 28 days of last scheduled work day
- Disability Date occurs during unscheduled work time and greater than 28 days after last scheduled work day
Less Than 12 Months Per Fiscal Year Employee Whose Disability Date Occurs When the Employee is Scheduled to Work and Continues Into Unscheduled Work Time
If your disability begins when you are scheduled to work, you would be eligible to use Sick/Personal Leave during the waiting period. You would then be eligible to receive the Supplemental Pay (100% of base pay for up to eight (8) weeks and then 80% of base pay for up to 18 weeks), provided you are scheduled to work. If you continue to be approved for STD into the period when you are not scheduled to work, the Supplemental Pay would end; you would receive only the Statutory Disability Benefit, currently up to $170 per week, as long as you remain disabled, during the remainder of time you are not scheduled to work. Effective the first day you are scheduled to return to work, you would be eligible for the Supplemental Pay; the amount of the Supplemental Pay is based on whether you are in the 100% Supplemental Pay Period or 80% Supplemental Pay Period.
Less Than 12 Months Per Fiscal Year Employee Whose Disability Date Begins Within 28 Days of Last Day Worked
Employee receives Statutory Disability Benefits during unscheduled work times and Statutory Disability Benefits plus Supplemental Pay during scheduled work times. Refer to the following examples to understand when Supplemental Pay is payable.
|Disability Begins During Unscheduled Work Time and Continues Into Scheduled Work Time||Disability Begins During Unscheduled Work Time and Continues Into Scheduled and Unscheduled Work Time|
Last Day Worked ‚Äì 5/31/12
Last Day Worked ‚Äì 5/31/12
Less Than 12 Months Per Fiscal Year Employee Whose Disability Date is Greater than 28 Days From Last Day Worked
Employee does not receive the Statutory Disability Benefit or Supplemental Pay during unscheduled work times. Employee receives the Statutory Disability Benefit and Supplemental Pay only during scheduled work times. Refer to the following examples to understand when the Statutory Disability Benefit and Supplemental Pay are payable.
|Disability Begins During Unscheduled Work Time and Continues Into Scheduled Work Time||Disability Begins During Unscheduled Work Time and Continues Into Scheduled and Unscheduled Work Time|
Last Day Worked ‚Äì 5/31/2012
Last Day Worked ‚Äì 5/31/2012
If You Become Disabled Again
If you were receiving STD benefits, recover from your illness/injury, and return to work your regular schedule, then become disabled again within 3 months of returning to work, due to the same or a related cause, your benefits may begin again without any Waiting Period. If, on the other hand, you become disabled due to a different cause, your benefits would begin after the Waiting Period.
In all cases, the duration for STD benefits will not be any greater than a total of 26 weeks in a rolling 52 week period, measured from the Disability Date.
Under New York State law, in order to be eligible for short-term disability (STD) benefits, an employee must be medically classified as totally disabled. Therefore, Prudential will only approve an employee‚Äôs initial STD claim if the employee is totally disabled; if the employee is not totally disabled, there will be no STD benefits payable.
After a period of approved total disability, an employee may recover enough such that he/she is able to return to work, but not at the regular work schedule. For example, a full-time employee may be able to return to work on a part-time basis. Since the person is no longer totally disabled, this can no longer be considered short-term disability under New York State law. Therefore, RIT has a self-insured partial disability benefit; under this benefit, an employee can return to work from an established total disability on a reduced work schedule so they can progress back to the regular schedule.
In order to be eligible for this partial benefit, the employee must have an existing total disability claim approved by Prudential. The employee can then apply for partial disability:
- The employee‚Äôs doctor must provide medical documentation to Prudential to support a partial return to work that outlines the work schedule, restrictions and duration;
- Prudential contacts RIT Human Resources with the details;
- RIT Human Resources provides the details to the employee‚Äôs manager/supervisor so he/she can determine if the partial disability can be accommodated and then notifies RIT Human Resources of the decision;
- If the department can accommodate the partial disability, Prudential will review the medical documentation to determine if it can be approved;
- If the department cannot accommodate the partial disability, RIT directs the employee to complete a Request for Accommodations Form to submit to RIT‚Äôs Compliance Manager for review.
- If Prudential approves the partial disability, the employee receives pay for the time worked and short-term disability pay for the time not worked.
The duration for the combined total disability period and partial disability period will not be greater than a total of 26 weeks in a rolling 52 week period, measured from the Disability Date.
If the partial disability is within the first 8 weeks and is, therefore, in the 100% Supplemental Pay Period, the employee will receive regular pay for the time worked and 100% pay for the time not worked. For example, if an employee is normally paid $100 per day and is working half time on a partial disability, the pay would be as follows:
|Pay for time worked||$ 50|
|100% partial disability||$ 50|
If the partial disability is after the first 8 weeks and is, therefore, in the 80% Supplemental Pay Period, the employee will receive regular pay for the time worked and 80% pay for the time not worked. For example, if an employee is normally paid $100 per day and is working half time on a partial disability, the pay would be as follows:
|Pay for time worked||$ 50|
|80% partial disability||$ 40|
Holiday Pay During Disability
If an employee is on STD on a University-designated holiday, the pay will be considered disability pay and not holiday pay.
Earning Vacation During Disability
Vacation credit is earned during short-term disability periods. When a disability crosses over into a new fiscal year, the employee may not use the new fiscal year‚Äôs vacation accrual until he/she physically returns to work.
Supplemental Pay When Employment Ends
If an employee is on STD when a planned retirement or termination date occurs, Supplemental Pay will end on the retirement/termination date. The Statutory Disability Benefit will continue if the employee remains disabled.
Disability Begins After Termination of Employment from RIT
If you are approved for STD within 4 weeks of your termination of employment, after an unpaid Waiting Period, the amount of your benefit would be the Statutory Disability Benefit. A former employee is not eligible for Supplemental Pay.
The following information is provided directly by the insurance company, The Prudential Insurance Company of America.
Procedures for Disability Claims and Appeals
How to File A Claim
If you wish to file a claim for benefits, you should follow the claim procedures described in this section. Prudential must receive your statement either telephonically or by submitting the information via the Web. Prudential will reach out directly to your physician‚Äôs office to secure the required medical information to review your claim.
Prudential will provide you notice of the decision on your claim no later than 45 days after the claim is filed. This time period may be extended twice by 30 days if it is determined that such an extension is necessary due to matters beyond the control of the Plan and notify you of the circumstances requiring the extension of time and the date by which we expect to render a decision. If such an extension is necessary due to your failure to submit the information necessary to decide the claim, the notice of extension will specifically describe the required information, and you will be afforded at least 45 days from receipt of the notice within which to provide the specified information. If you deliver the requested information within the time specified, any 30 day extension period will begin after you have provided that information. If you fail to deliver the requested information within the time specified, Prudential may decide your claim without that information.
If your claim for benefits is wholly or partially denied, any notice of adverse benefit determination under the Plan will
- state the specific reason(s)for determination
- reference specific Plan provision(s)on which the determination is based
- describe additional material or information necessary to complete the claim and why such information is necessary
- describe Plan procedures and time limits for appealing the determination, and your right to obtain information about those procedures and the right to sue in federal court
- disclose any internal rule, guidelines, protocol or similar criterion relied on in making the adverse determination (or state that such information will be provided free of charge upon request)
Notice of the determination may be provided in written and/or electronic form. Electronic notices will be provided in a form that complies with any applicable legal requirements.
You have 180 days from the receipt of notice of an adverse benefit determination to file an appeal. Requests for appeals should be sent to the address specified in the claim denial. A decision on review will be made not later than 45 days following receipt of the written request for review. If Prudential determines that special circumstances require an extension of time for a decision on review, the review period may be extended by an additional 45 days (90 days in total). Prudential will notify you in writing if an additional 45 day extension is needed. If an extension is necessary due to your failure to submit the information necessary to decide the appeal, the notice of extension will specifically describe the required information, and you will be afforded at least 45 days from receipt of the notice to provide the specified information. If you deliver the requested information within the time specified, the 45 day extension of the appeal period will begin after you have provided that information. If you fail to deliver the requested information within the time specified, Prudential may decide your appeal without that information. You will have the opportunity to submit written comments, documents, or other information in support of your appeal. You will have access to all relevant documents as defined by applicable U.S. Department of Labor regulations. The review of the adverse benefit determination will take into account all new information, whether or not presented or available at the initial determination. No deference will be afforded to the initial determination.
The review will be conducted by Prudential and will be made by a person different from the person who made the initial determination and such person will not be the original decision maker‚Äôs subordinate. In the case of a claim denied on the grounds of a medical judgment, Prudential will consult with a health professional with appropriate training and experience. The health care professional who is consulted on appeal will not be the individual who was consulted during the initial determination or a subordinate. If the advice of a medical or vocational expert was obtained by the Plan in connection with the denial of your claim, Prudential will provide you with the names of each such expert, regardless of whether the advice was relied upon. A notice that your request on appeal is denied will contain the following information:
- the specific reason(s)for the appeal determination
- a reference to the specific Plan provision(s)on which the determination is based
- a statement disclosing any internal rule, guidelines, protocol or similar criterion relied on in making the adverse determination (or a statement that such information will be provided free of charge upon request)
- a statement describing your right to bring a civil suit under federal law
- a statement that you are entitled to receive upon request, and without charge, reasonable access to or copies of all documents, records or other information relevant to the determination
- a statement that "You or your plan may have other voluntary alternative dispute resolution
- options, such as mediation. One way to find out what may be available is to contact your local U.S. Department of Labor Office and your State insurance regulatory agency
Notice of the determination may be provided in written and/or electronic form. Electronic notices will be provided in a form that complies with any applicable legal requirements. Unless there are special circumstances, this administrative appeal process must be completed before you begin any legal action regarding your claim.