How are benefits obtained?— continued
7. In addition to completing the claim form (DBL-1 or DBL-2), you should attach the documentation specified as follows:
Regular Pedagogical Appointees:
- A signed copy of the approved Department of Education Confidential Medical Report Form OP407 (page 2 only) (Leave of Absence for Restoration of Health), or
- Department of Education Form OP#160, signed by the Superintendent or Personnel Liaison, or
- Department of Education approved FMLA (Family Medical Leave Act) Leave for Personal Illness or Maternity, as applicable.
- A copy of the Department of Education form “Application for Leave of Absence for Employees in Paraprofessional Titles”, with “Approval” indicated in the appropriate section by the Medical Director for those on authorized sick leave without pay, or
- The Department of Education approved FMLA (Family Medical Leave Act) Leave for Personal Illness or Maternity, as applicable.
Paraprofessionals:
Non-pedagogical employees:
- A copy of the Department of Education form, “Application for Leave of Absence for Employees in Educational Titles”, with “Approval” indicated in the appropriate section by the Medical Director for those on authorized sick leave without pay, or
- A copy of an approved Department of Education FMLA (Family Medical Leave Act) Leave for Personal Illness or Maternity, as applicable, or
- A letter from your Supervisor stating that you would have been regularly assigned for the term had it not been for your illness or injury.
Regularly Assigned Substitutes:
- A copy of an approved Department of Education FMLA (Family Medical Leave Act) Leave for Personal Illness or Maternity, as applicable, or
- A letter from your Principal stating that you would have been regularly assigned for the term had it not been for your illness or injury.
Other Covered Members:
When your DBL-1 Initial Application is received by the Fund Office, you will be advised of any additional documentation that is required.
It should be noted that:
1. Whenever applicable, proof of the child’s birth must be submitted.
2. All Department of Education forms specified above are issued by the Department of Education and may be obtained from your Payroll Secretary OR the Department of Education website- schools.nyc.gov. These forms are not available from the Fund Office.
Line of Duty Injuries/Medical Arbitration
Members, who are injured in the line of duty and/or have had to apply for medical arbitration, should file for disability using the procedures outlined above. However, a copy of the medical arbitration decision must accompany the claim form. Upon receipt of these documents, the Fund will review the disability claim for processing.
What is not covered under the Disability Plan?
No benefits shall be paid:
1. For any period for which there has not been proper filing.
2. For any period for which pay is received from the Department of Education.
3. For any period during which benefits are paid or payable under any unemployment compensation or similar laws.
4. For any period during which the member is not under the care of a legally licensed physician for the condition causing the disability.
5. For any period of disability that commences while a member is not covered under the UFT Welfare Fund rules of eligibility.
6. For any period of disability due to willfully and intentionally self-inflicted injury or sickness or to injury sustained in the commission of a crime.
7. For any period during which pension is received from any governmental retirement service or upon retirement from the Department of Education.
8. For any period during which benefits are paid or
payable under the New York State or other jurisdiction’s
No-Fault Insurance Law. This exclusion is not applicable
after no-fault benefits are exhausted. A letter from the no-fault
insurance carrier confirming this must accompany
your
DBL-1.
9. For any period for which reimbursement may be obtained from any other third party, such as by way of litigation arising out of an accident, or otherwise, unless a written assignment or lien in a form acceptable to the Fund is executed by the claimant to the Fund for the amount claimed.