Claim investigations may include obtaining medical and hospital records, independent medical examinations and other pertinent information. The length of time required to investigate (and therefore, approve or deny a claim) varies with each claim, depending on the circumstances.
Extent/degree of disability test
All disability claims are subject to an extent or degree of disability test, regardless of the number of years of service credit the member had when he or she became disabled.
An extent or degree of disability investigation may include requesting hospital records and getting additional medical information from the member’s attending physician(s) or possibly having the member examined by a physician chosen and paid for by IMRF.
If the claim appears to involve an extent or degree of disability condition, an IMRF Claims Examiner will review the claim. If the Claims Examiner determines that the member’s disability does not prevent him or her from performing the duties and responsibilities of any position that might reasonably be assigned by the current IMRF employer, the member will be advised that the claim for disability benefits is being denied.
In some cases, IMRF compiles a written summary of the member’s medical history for review by IMRF’s rehabilitative medicine/occupational psychiatric consultant.
If the member applied for temporary disability benefits:
If it is the rehabilitative medicine/occupational psychiatric consultant's opinion that the member’s disability:
Prevents him or her from performing the duties and responsibilities of any position that might reasonably be assigned by the current IMRF employer, the claim will be returned to a disability claims examiner for payment processing (assuming the member is currently receiving IMRF temporary disability benefits).
Does not prevent him or her from performing the duties and responsibilities of any position which might reasonably be assigned by the current IMRF employer, medical the claim is denied and the member is so advised.
If the member’s claim is being reviewed for total and permanent disability benefits:
If it is the rehabilitative medicine/occupational psychiatric consultant’s opinion that the member’s disability:
Prevents him or her from working in any gainful activity for any employer, the claim will be returned to a disability claims examiner for payment processing (assuming the member is currently receiving IMRF temporary disability benefits).
Does not prevent him or her from working in any gainful activity for any employer, the claim is denied and the member is so advised.
If the member's claim is denied, the member will be advised of his or her right to request a hearing before the Benefit Review Committee of the IMRF Board of Trustees.
Medical certification
Medical certification refers to the member’s attending physician’s statement (IMRF Form entitled, ”Physician’s Statement – Temporary Disability Claim”). IMRF may also require IMRF Forms entitled ”Disability Claim Data,”” Physician’s Statement – Temporary Disability Claim Continuation,” or ”Physician’s Statement – Total and Permanent Disability Claim.” If any of these forms are required, IMRF will mail the form(s) directly to the member. Members of the Elected County Official Plan must submit two medical certifications: “Physician’s Statement – Temporary Disability Claim” and ”Physician’s Statement - Disability Claim for Elected County Officials.”
A member can access IMRF Form entitled, "Physician's Statement - Temporary Disability Claim" by visiting the Member Access area on IMRF's website (www.imrf.org).
When the member first applies for disability benefits, he or she should ensure that the physician’s statement indicates any office visits or services rendered after the date the member became disabled. IMRF will send a letter to the member’s attending physician requesting office visit and treatment notes.
If the member is approved for disability benefits and begins receiving benefit payments, the IMRF law requires that members periodically submit, at their own expense, medical evidence of continuing disability.
The evidence is required to determine if the member remains eligible for IMRF disability payments. If the member fails to submit current medical evidence of the disabling condition, IMRF must stop disability benefit payments.
Pre-existing condition investigations for total and permanent disability claims
Whether a pre-existing condition investigation is done depends on how much IMRF service credit the member has on the date the disability condition occurred..
The member had FIVE OR MORE YEARS of service credit
The member’s claim is not investigated for a pre-existing condition if the member has at least five years of IMRF service credit, excluding service credit earned while receiving IMRF disability benefits.
The member had FEWER THAN FIVE YEARS of IMRF service credit
A pre-existing condition investigation will be done if the member has fewer than five years of service credit on the date he or she became disabled.
IMRF will request information to determine if the member had the disabling condition before becoming an IMRF participant.
IMRF will request information to determine if the member was treated in the three-year period prior to his or her IMRF participation date using the beginning date of the member’s most recent uninterrupted IMRF participation.
This investigation includes having the member complete Form 5.40A, ”Disability Claim Data,” and Form 5.46, ”Authorization For Disclosure of Health Information,” which gives IMRF permission to request hospital records and to write to the member’s attending physician(s).
If the member’s claim appears to involve a pre-existing condition, an IMRF Claims Examiner will review the claim. If the Claims Examiner determines the member’s disability is the result of a pre-existing condition, the member will be advised that the claim for IMRF total and permanent disability benefits is being denied. If the member disagrees with that decision, he or she can request a hearing before the Benefit Review Committee of the IMRF Board of Trustees
In some cases, IMRF compiles a written summary of the member’s medical history for review by IMRF’s rehabilitative medicine/occupational psychiatric consultant. If it is IMRF’s rehabilitative medicine/occupational psychiatric consultant’s opinion that the disability is not the result of a pre-existing condition, the claim will be returned to the disability claim examiner for payment processing.
If it is the opinion of the IMRF staff and of the IMRF rehabilitative medicine/occupational psychiatric consultant that the disability is the result of a pre-existing condition, the member will be advised that the claim for IMRF total and permanent disability benefits is being denied. The member will also be advised of his or her right to request a hearing before the Benefit Review Committee of the IMRF Board of Trustees if the member disagrees with the denial. (See 5.70 Appeal Rights for further discussion of appeal rights.)