Facing a disability is challenging in itself, but when a claim for short-term disability benefits gets denied, it adds another layer of stress and uncertainty. In this blog post, we’ll delve into some of the common reasons why short-term disability benefits such as California State Disability Insurance (SDI). We’ll also explore the steps you can take if your application is rejected to ensure you get the benefits you deserve.
What Is California State Disability?
Administered by the Employment Development Department (EDD), California State Disability Insurance is a short-term benefit for California workers who lose wages due to a non-work-related illness, injury, or pregnancy. The majority of workers in California are covered by California SDI in the event they become unable to work due to a disability. California workers pay for this insurance policy through their employer payroll deductions. The exception to this is contract workers, who are not covered by California SDI unless they pay additional Disability Insurance Elective Coverage (DIEC).
California SDI is commonly referred to as short-term disability because the benefit can only last for one year at most. If your disability lasts longer than one year, you may be eligible for long-term Social Security disability. You can receive Social Security Disability Insurance (SSDI) from the Social Security Administration (SSA) for many years until you reach full retirement age.
While California SDI is not a replacement of 100% of your lost wages due to disability from work, you can receive 60–70% of the wages you earned in the 5–18 months prior to the date your work stopped due to a disability. To get an estimate of your monthly California SDI benefit, use the EDD’s online calculator.
What Are the Eligibility Requirements for California State Disability?
In order to receive California SDI, you must:
- Be unable to do your regular or customary work for at least eight days.
- Have lost wages because of your disability.
- Be employed or actively looking for work at the time your disability begins.
- Have earned at least $300 from which State Disability Insurance (SDI) deductions were withheld during your base period. Learn more with Calculating Benefit Payment Amounts.
- Be under the care and treatment of a licensed physician/practitioner or accredited religious practitioner within the first eight days of your disability. The date your claim begins can be adjusted if it does not meet this requirement. You must remain under care and treatment to continue receiving benefits.
What Is the Deadline for Filing for California State Disability?
In order to avoid delays with the processing of your claim, you should file your application between 9 and 49 days after you stop working.
Top Reasons for Short-Term Disability Denials
Understanding why California SDI claims are denied can help applicants navigate the process more effectively. Here are some of the reasons why SDI applications are denied:
Self-employment and no SDI coverage
If you are self-employed and did not opt for California SDI coverage, then you likely are not eligible for California SDI because you have not paid into the system. California SDI operates as a type of disability insurance program that is funded through payroll taxes through one’s employer, a requirement for eligibility.
However, if you elected to pay California State Disability Insurance through Disability Insurance Elective Coverage as a self-employed worker, you may be eligible for the benefit if you have a sufficient base period of covered wages prior to the filing date. Business owners, contractors, entrepreneurs, and self-employed individuals in California are eligible to enroll in DIEC and may receive up to 39 weeks of SDI benefits. However, if you have not elected this coverage, your claim may be denied on the basis that you have not funded your EDD account.
Lack of medical support
If your medical providers do not support your California SDI claim, then the EDD will not approve your claim. It’s important to discuss your disability with your medical provider to prevent your claim from being denied for lack of support. Your doctor must certify your disability using form DE 2501F. They must also certify your California SDI claim online. Without certification, your claim may be denied.
Not meeting the definition of disability
If you are able to perform the job you were previously working in spite of your disability, you are not eligible for California SDI. Further, you must have lost wages due to your disability, you must be employed or actively looking for work when your disability begins, and you must be under the care of a licensed physician or practitioner within the first eight days of your disability.
Insufficient waiting period
In the State of California, the EDD requires that you file for disability no earlier than nine days after your disability begins. If you file for California SDI too soon after you stop working, your claim may be denied on the basis that you have not been out of work for nine days due to your disability.
Filing a claim for a non-covered condition
In order to qualify for California State Disability Insurance, you must be unable to work due to a non-work related disability. The program defines disability as “an illness or injury, either physical or mental, which prevents you from performing your regular and customary work. Disability also includes elective surgery, pregnancy, childbirth, or other related medical conditions.”
As you can see, this definition covers a wide range of potential medical conditions. However, the definition of disability does not cover a disability or injury that is work-related. If your disability or injury is derived from your work, you are likely covered by your employer’s worker’s compensation coverage. If you are not sure whether your disability is work-related, a physician may determine the cause of your condition.
Errors in application
Your claim for California SDI may be denied on the basis that you provided incomplete or inaccurate information. For example, if you had a previous claim for California SDI or unemployment benefits using a different email address, you may receive error messages on your application.
Missed deadlines
To avoid disqualification for California SDI, you must wait 9 days after the start date of your disability, and file your claim within 49 days of the start date of your disability. If you miss this deadline, you should provide a letter stating a good reason for missing the deadline.
What to Do if Your Claim Gets Denied
If your California State Disability Insurance claim is denied, don’t lose hope. Understanding your options for appeal and seeking guidance from professionals experienced in navigating the process can significantly improve your chances of a successful outcome.
Take the following steps if your SDI claim is denied:
Review the denial letter
For denied claims, the California EDD will send you a Notice of Determination, which states the reasons for your denial. Understanding the reasons for being denied state disability benefits is crucial, as it enables you to address deficiencies in your claims and increase the likelihood of a successful appeal or reapplication.
Collect additional evidence
The Notice of Determination may state that your claim is missing information, such as identification documents. List down these deficiencies and collect them prior to filing an appeal.
Appeal the decision
Once you have gathered any additional evidence and stated the basis for your appeal, you should mail your appeal to the return address shown on the Notice of Determination. You can appeal the denial of your California SDI application by filing an Appeal Form (DE 1000A).
If your appeal is denied, the Office of Appeals will mail you a notification with your hearing date, time, location, and their phone number. At the hearing, an impartial administrative law judge will listen to both sides of the appeal and make a decision based on facts presented by you and by a State Disability Insurance representative. If you fail to appear, your appeal will be dismissed. You should contact an attorney who specializes in California State Disability law to discuss possible representation at your hearing.
Maintain communication records
You should keep copies of all forms and documents you receive and send to the EDD. Where possible, you should send mail via registered return receipt.
Consult a legal professional
As with many areas of life, consulting an experienced professional can save you time and money in the long run. A lawyer trained in California state disability law can help you navigate a complex bureaucracy, time your application for SDI to maximize your net benefit, help with the process of transitioning from EDD unemployment to California SDI, and appeal any unfavorable decisions.
LaPorte Law Firm specializes solely in Social Security disability law. However, many of our clients receive California SDI benefits while their case is pending with the Social Security Administration. To find out more about the interaction between these two programs, including how your SDI benefit may reduce your monthly Social Security benefit for months in which you are entitled to both SDI and SSDI benefits, contact our office to schedule a free consultation.
FAQs
You should consult an attorney trained in California state disability law. Review the denial notice to find out why your case was denied and see if the EDD is missing any documents. If you missed the deadline to file a California SDI application, you may have had a good reason for doing so, and you can appeal the denial.
You can appeal the denial of your California SDI by filing an Appeal Form (DE 1000A). Your appeal should be mailed to the return address listed on the letter. If possible, mail your appeal via registered return receipt.
