ADMINISTRATIVE MANUAL
INSTRUCTIONS FOR COMPLETING THE
APPLICATION FOR SHORT TERM DISABILITY BENEFITS
In order to establish effective communication and to provide a high quality service, we
want to guide you in handling the Short Term Disability Benefits claims (STDI, ADSO,
WKDB).
The application consists of three (3) parts, which must be completed in full by the
person specified on each part, as follows:
Part A - Claimant (Employee)
Important – signed authorization to request medical information.
Part B - Employer (Human Resource, Finance Dept., Benefits Manager, etc.)
Part C - Physician (who certify the disability)
AUTHORIZATION TO REQUEST MEDICAL INFORMATION
The authorization to obtain medical information is important because it allows the
insurance company to discuss and obtain additional information needed to make a
decision on the submitted claim. The authorization must be signed by the employee or
authorized person if the employee is unable to sign or does not have the capacity.
Upon completion of the three parts of the claim form, the employee must submit the
original application to our offices as soon as possible. We will not accept copies of
any of the parts.
Below are instructions for completing the claim form.
PO BOX 363786
SAN JUAN PR 00936-3786
TEL (787) 758-4888
FAX (787) 766-1985
www.sssvida.com
1
CLG-0611-49
PART A
CLAIMANT’S REPORT
This part consists of 17 questions which must be answered in full with accurate data.
In those for which there is no response, indicate Not Applicable (N/A).
A. Postal Address - To avoid delay in processing mail, you must ensure that the
address is correct and clearly written, because payments (checks), letters and
other correspondence will be mailed. No payments will be deliver personally in
our office.
B. Before submitting the application, please verify that the employee has answered
all questions in Claimant's Report. If the employee's disability was due to an
accident unrelated to work or car accident, you must answer question number
nine (9) in detail as specified therein.
C. If the employee chooses to file or filed a claim with the State Insurance Fund
(FSE), after the claim submission, call immediately and report the FSE case
number.
D. If the employee receives approval or denial of the Federal Social Security
Administration due to disability or age, you must send a copy of the letter "Notice
of Award”.
E. It is important that the disabled employee sign the:
Certification of information provided.
Authorization to provide medical information necessary for the appropriate
action of the claim. Both appear at the bottom of Part A.
Additional Details:
Any alteration, erasure, deletion, change of ink color or type of writing in the
report should be initiated by the employee.
PO BOX 363786
SAN JUAN PR 00936-3786
TEL (787) 758-4888
FAX (787) 766-1985
www.sssvida.com
2
CLG-0611-49
PART B
EMPLOYER’S REPORT
This part of the application is critical to determine: the waiting period to apply and
the amount to be paid to the claimant.
Here we highlight some boxes to be completed:
A. Box 7: Please indicate the last day the employee physically stopped working.
This date must match with the employee's response from box 8 (Part A).
B. Box 12: Have you make any payment... Should indicate whether a payment
was issued to claimant. If yes, indicate type of payment and date issued.
It is necessary to inform the holidays that the employee make used or collected
during the reporting period claimed. Do not include paid holidays under the
concept of sick leave, regular vacations, maternity leave or other payments, but
under the box that applies.
According to the employee's working days, inform the period covered by the
payment of salaries (from - to). Indicate the number of days paid, not hours paid,
set the gross amount and date of payment. The information must be accurate,
because we deduct benefits during the period for which the employer paid full
wages.
Employer’s payments during disability - If the employer states in box 12 that they
have paid full salary for regular vacations or sick leave, holidays, or other
voluntary payments during the period of disability, the disability payment maybe
are reduced by the number of days paid.
If payment is due to maternity leave - in order to establish that working mothers
received the full salary, wages or compensation to begin his rest period, the
employer is liable to pay 100% of wages during the rest period and no benefits
are payable during that period.
If the employer reports wages paid, it is important to indicate the starting date for
each payment.
Based on the date or dates indicated and the total of days paid, the examiner
may determine when the plan must begin to enforce their weekly payments.
PO BOX 363786
SAN JUAN PR 00936-3786
TEL (787) 758-4888
FAX (787) 766-1985
www.sssvida.com
3
CLG-0611-49
C. Certification and Signature - All Employer’s Report must be signed by an
authorized officer including his title, in addition to other required information. It
is very important to indicate the address and phone number to ensure effective
communication.
D. Payments are based on 1/7 for days and not 1/5 as the payroll.
Additional Details:
Be sure not to leave blank lines or boxes in your share.
Report the employee's regular weekly salary and the regular weekly schedule
(hours) in boxes 4 and 5.
Verify that the certification form is signed.
Any alteration, erasure, deletion, change of ink color or type of writing in the
report should be initiated by the employee.
PO BOX 363786
SAN JUAN PR 00936-3786
TEL (787) 758-4888
FAX (787) 766-1985
www.sssvida.com
4
CLG-0611-49
PART C
MEDICAL CERTIFICATION
This section consists of 11 questions which must be fully answered with accurate
data by the physician certifying the disability.
A. The diagnosis indicated in box 2 must be legible and preferably with ICD9-CM
code for the condition. If the disability is for complications of pregnancy or
while the patient is in her period of pregnancy, you must specify the condition
or complications that unable her to return to work.
B. Guide your employee that we wouldn’t be process any claim where in item 4
and 5, indicating a period of "Indefinite", "Indeterminate" or "At present". If so,
the Medical Certification will be returned to indicate the probable date of
recovery (Month/Day/Year).
C. If the medical certificate of the application is incomplete, altered or crossed out
without the initials of the physician, physician's signature is missing and / or
license number is missing, cannot be accepted and will be sent to the
employee to submit and complete medical information as required.
Additional Details:
Guide your employee to notify the doctor to use legible letters especially in
diagnosis or code.
The employee must check the entire form before leaving the doctor's office.
Any alteration, erasure, deletion, change of ink color or type of writing in the
report should be initiated by the employee.
PO BOX 363786
SAN JUAN PR 00936-3786
TEL (787) 758-4888
FAX (787) 766-1985
www.sssvida.com
5
CLG-0611-49
GENERAL CONSIDERATIONS
The Notice of Loss must be filed within ninety (90) days following the date of
loss or as soon as reasonably possible but in no time, except in the absence
of legal capacity, after one (1) year of date on which otherwise the
presentation of such evidence was requested.
Incomplete applications (no information), will delay the evaluation process,
the issue of payment and/or determination of claim.
Any claim received properly completed, will be processed for payment in
order of arrival.
To check the status of a claim, it is important that when you call please have
the name of the claimant. If you have been assigned a claim number, you
can refer to it.
In cases where the employee is receiving services and/or benefits from the
State Insurance Fund, you must send the original claim with copies of
medical records, copy of Employer's Report, Medical Certificate (CFSE
1021), Final Decision Manager (Form 304), Form CFSE 395 and a copy of
the appointments card.
Direct Deposit (ACH) – It is highly recommended as it avoids mail delays and
loss of payment. We will deposit the payment of his claim directly to the bank
account to those want to use this system. For this you must complete the
attached form and submitted with VOID check (Current or Checking Account),
deposit slip or bank statement with account number pre-printed (Savings
Account).
Compliance with these recommendations will result in benefits to the
claimant, as we can expedite the claim process, avoid the impact that lack of
income leads to the employee.
We count with your cooperation to provide the best service to our claimants.
PO BOX 363786
SAN JUAN PR 00936-3786
TEL (787) 758-4888
FAX (787) 766-1985
www.sssvida.com
6
CLG-0611-49
APPLICATION FOR SUPPLEMENTARY PROOF OF PAYMENTS
FOR SHORT TERM DISABILITY BENEFITS
(STDI, ADSO, WKDB)
The application for supplementary proof of payment for Short Term Disability
Benefits (STDI, ADSO, WKDB) will be sent with each paycheck claim, except for a
final payment.
The application consists of three (3) parts. Always will be required to complete the
claimant’s part (1). The examiner in charge of the claim determines whether it is
necessary to complete the medical part (2) or the employer (3), as part of the
evaluation process of the claim.
This document must be sent to our offices as soon as possible to continue the
evaluation process of the claim. The claim will not be assessed for payment until it
receives the Supplementary Proof of Payments.
If the claimant has returned to work within the period of disability certified by your
doctor, you must indicate this on the Supplementary Proof of Payments (part of the
claimant or employer) and send it to our offices as soon as possible. If you do not
report, you may incur in overpayment which would require us to request a full refund
of the overpayment.
If we do not receive the continuation form completed in all parts requested, it
will leads the closure of the claim.
PAYMENT OF LOSS
We will make payments for covered losses promptly, in accordance with the terms
and conditions of the master policy, once we receive in our main office due proof of
loss satisfactory to us. All benefit payments will be made to the claimant.
Any accrued but unpaid compensation as of the date of death of the insured shall be
payable to the surviving spouse, or failing that, to the legal heirs of the insured
equally.
PO BOX 363786
SAN JUAN PR 00936-3786
TEL (787) 758-4888
FAX (787) 766-1985
www.sssvida.com
7
CLG-0611-49
GROUP CLAIMS DEPARTMENT
(For Administrative use only)
(787) 758-4888
Manager Group Claims Dept.
Sandra Montañez
Ext. 4875
Secretary & Group Life Examiner
Ginnette M. Hernández
Ext. 4882
Supervisor Group Claims Dept.
Jacqueline Campos
Ext. 4617
Examiner of SINOT, STDI, WKDB & ADSO
Nilda Rodríguez
Dolores Ríos
Examiner of LTDS
Aileen Gallardo
Luis López
Clinical Management
Mayra Gumá
José González
Ext. 4633
Ext. 4692
GROUP SERVICE DEPARTAMENT
Group Service Dept. Supervisor
Eunice Carrión
Ext. 4804
External Group Service Representatives
Melyssa Oliveras
Ivelisse Matos
Lilybeth Moyett
Ext. 4448
Ext. 4612
Ext. 3386
Internal Group Service Representatives
Joel Rodríguez
Jessica Vélez
Arturo Carrión, Jr
PO BOX 363786
SAN JUAN PR 00936-3786
TEL (787) 758-4888
FAX (787) 766-1985
www.sssvida.com
Ext. 4613
Ext. 4614
Ext. 4608
8
CLG-0611-49
SERVICE CENTERS
We have our main offices, an integrated service center and four (4) regional offices
to facilitate access and services to our policyholders. These offices are directed and
handled cases of employers and policyholders. Serve as liaison for the processing of
claim forms. Our network of offices will enable more effective and efficient access to
our services throughout the island.
Home Office, Río Piedras
Customer Service Offices
Lobby (Denny’s Rest. Against)
1052 Ave Luis Muñoz Rivera
Río Piedras, PR 00927
Monday to Friday – 8:00am a 4:30pm
Tel. (787) 758-4888, option 4 (Group Service Department)
Integrated Services Centre
Plaza Las Américas
Service Center of Plaza las Américas
Second Floor (Relojes y Relojes Against)
Monday to Thursday – 8:30am a 5:00pm
Friday – 8:30am a 1:00pm
Tel: (787) 758-4888, ext. 4600
All mail correspondence should be sent to:
Triple-S Vida, Inc.
Dep. Reclamaciones Grupal
PO Box 363786
San Juan, PR 00936-3786
PO BOX 363786
SAN JUAN PR 00936-3786
TEL (787) 758-4888
FAX (787) 766-1985
www.sssvida.com
9
CLG-0611-49