Each case is thoroughly evaluated by the Third Party Administrator (TPA) based on the medical information provided by the health care provider and how that medical condition applies to the policy. A catastrophic leave request may be denied because the condition does not meet the criteria as listed in the policy or if the documentation lacks sufficient information to support an approval of catastrophic leave.
If an employee’s case is denied, then he/she will have the ability to file an appeal. There are two appeal processes in place depending on the reason for denial. If an application is denied by a manager due to misuse or abuse of leave, the employee can appeal to the next level manager. If an application is denied by the TPA due to medical reasons, the applicant can have their health care provider resubmit their application with additional medical details. With an appeal, the TPA will assign a new health care provider to review the medical documentation. The application will then be reevaluated based on the new information provided.
Any denial for reasons of misuse of leave or medical review can be appealed to the Vice President of Human Resources. The decision of the VP of HR may be appealed to the Board of Regents as per Regents’ Policy, Section 1.5.