Leave Of Absence Application (Page 3 of 4) in pdf

When a leave becomes unpaid, employees are not eligible for holiday pay nor do they

accrue PPL, SBL, or ESL until they return to work.

If you do not return to work after the expiration of the leave, you will be required to reimburse

TSRI for all insurance premiums paid by TSRI during the leave.

7. COBRA

If your leave of absence exceeds 12 weeks and you desire to continue medical and dental

insurance coverage beyond the 12 weeks paid by TSRI, you may exercise your rights under

the provisions of the Consolidated Omnibus Budget Reconciliation Act (COBRA). However,

if your leave goes beyond 12 weeks and you are still paid by TSRI, benefits may be

continued until such time paid leave balances are depleted. Once a leave becomes unpaid

the employee may then exercise his/her rights under COBRA. Information on this may be

obtained from a Benefits Representative in Human Resources.

If you are a participant in the Health Care Spending Account (HCSA) and your leave of

absence exceeds 12 weeks, you may continue your participation through COBRA. If you do

not choose the COBRA option, you must submit a new Benefit Coverage Change Form to

Human Resources within 31 days of your return from leave in order to restart your HCSA.

If you do not choose the COBRA option, medical and dental benefits will be restarted at the

time you return from your approved LOA without evidence of insurability or a new pre-

existing condition applying.

2017 Monthly Medical and Dental Rates under COBRA

Medical

Comprehensive HDHP PPO

HMO

EPO

Dental

Employee Only

$737.92

$518.98

$498.16

$387.03

$39.77

Employee + Child/ren

$1232.26

$866.64

$832.00

$741.36

$66.42

Employee + Spouse

$1475.55

$1037.58

$996.32

$921.38

$79.55

Employee + Family

$1970.21

$1385.63

$1330.44 $1179.57 $106.22

8. Requirements to Return to Work from a Leave

A healthcare provider’s certification that you are fit for duty is required prior to your return

from your leave. If applicable, the healthcare provider's statement must also specify any

work restrictions recommended and for what period of time they apply.

9. Reinstatement at Conclusion of Leave

TSRI will reinstate an employee to her former or comparable job if she returns from a

pregnancy-related disability leave immediately following the expiration of approved leave,

unless the employee would not otherwise have been employed if leave had not been taken.

10. Failure to Return at Conclusion of Leave

Failure to return to work at the end of the approved leave will be deemed a voluntary

resignation, unless approval for an extension is granted by the supervisor and the Human

Resources Department one week prior to the end of the leave.

Effective: 01/01/2017

Leave Of Absence Application Page 3

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