Basic Eligibility for Your Employees
Eligibility for Disability Insurance (DI)
DI benefits can be paid only after your employees meet all of the following requirements:
- The individual must be unable to do their regular or customary work for at least eight consecutive days.
- The individual must be employed or actively looking for work at the time they become disabled.
- The individual must have lost wages because of their disability or, if unemployed, have been actively looking for work.
- The individual must have earned at least $300 from which State Disability Insurance (SDI) deductions were withheld during a previous period. The individual must be under the care and treatment of a licensed physician/practitioner or accredited religious practitioner during the first eight days of their disability. (The beginning date of a claim can be adjusted to meet this requirement.) The individual must remain under care and treatment to continue receiving benefits.
- The individual must complete and submit a claim form within 49 days of the date they became disabled or may lose benefits.
- The individual’s physician/practitioner must complete the medical certification of their disability. A nurse practitioner may certify to a disability within his/her scope of practice however, he/she must perform a physical examination and collaborate with a physician or surgeon. A licensed midwife, nurse-midwife, or nurse practitioner may complete the medical certification for disabilities related to normal pregnancy or childbirth. (If the individual is under the care of a religious practitioner, request a “Practitioner’s Certificate,” DE 2502, from an SDI office. Certification by a religious practitioner is acceptable only if the practitioner has been accredited by Employment Development Department.
An independent medical examination to determine the individual’s initial or continuing eligibility may be required.
Ineligibility - DI
Your employee may apply for benefits even if they are not sure they are eligible. If they are found to be ineligible for all or part of a period claimed, they will be notified of the ineligible period and the reason. Your employee may not be eligible for DI benefits if they:
- Are claiming or receiving Unemployment Insurance (UI) or Paid Family Leave (PFL) benefits.
- Became disabled while committing a crime resulting in a felony conviction.
- Are in jail, prison, recovery home, or any other place because they were convicted of a crime.
- Are receiving workers’ compensation benefits at a weekly rate equal to or greater than the DI rate.
- Fail to have an independent medical examination when requested to do so.
Eligibility for PFL
Employees covered by SDI are also covered for PFL. If a Voluntary Plan insurer provides your company’s disability insurance coverage, then it must also provide PFL coverage.
An employee may submit a claim for PFL insurance benefits for the following reasons:
- To care for a seriously ill child, parent, parent-in-law, grandparent, grandchild, sibling, spouse, or registered domestic partner.
- To bond with the employee’s new minor child or the new minor child of the employee’s spouse or registered domestic partner.
- To bond with a minor child in connection with the adoption or foster care placement of the child with the employee or the employee’s spouse or registered domestic partner.
A serious health condition means an illness, injury, impairment, or physical or mental condition of a patient that involves inpatient care in a hospital, hospice, or residential medical care facility. This includes any period of incapacity (e.g., inability to work, attend school, or perform other regular daily activities) or any subsequent treatment in connection with such inpatient care; or continuing treatment by a physician/practitioner unless complications arise. Cosmetic treatments, the common cold, influenza, earaches, upset stomach, minor ulcers, and headaches other than migraine are examples of conditions that do not meet the definition of a serious health condition for purposes of PFL benefits.
Ineligibility - PFL
Your employee may not be eligible for PFL benefits if they:
- Receive DI, UI, or workers’ compensation.
- Are not working or looking for work at the time they begin their family care leave.
- Are not suffering a loss of wages.
- Are in custody due to conviction of a crime.
- Cannot provide certification by the treating physician/practitioner that they are needed for care.