INDUSTRY TERMS

“Appropriate Care” means that you are receiving consultation and treatment from a physician or physicians who are qualified to render treatment and care for your claimed disability impairment. Most disability policies require insureds and claimants to be treated by physicians with specialties related to the specific impairment or disability.

Typical activities of daily living include: toileting, bathing, ability to prepare food, transferring (from bed to walking etc.), and dressing oneself. Commonly referred to as “ADL’s”, these activities are often reported by your physician and represent the degree to which one can take care of their basic needs.”

Deductible sources of income, or “offsets” are reductions from your gross benefit. This is income which you receive, or are entitled to receive, while you are disabled. Deductible sources of income are listed under “Other Monthly Earnings” in the policy contract.

Disability insurance is intended to replace wages, salary or income during periods of medical impairment which prevent you from performing the important duties of your occupation or job. It should NOT be regarded as retirement income, unemployment insurance, or worker’s compensation.

If your date of disability occurs before the date you are covered under your group LTD plan, you are not insured, and therefore would not be eligible for benefits. The effective date of coverage is generally the first of the year following an annual enrollment period for which you are covered by your employers group plan. You are covered by the LTD plan when you have met the conditions of the “waiting period” as outlined in the policy.

This is a period of time for which benefits are NOT paid beginning with your Date of Disability and ending the day after the last day of the elimination period. All group Long-Term LTD policies have Elimination Periods in an attempt to eliminate relatively short term illness from collecting long-term benefits. Some group STD plans have “no EP” which means you can begin collecting right away. Many people get confused in differentiating between a WAITING PERIOD and an ELIMINATION PERIOD. Remember, a WAITING PERIOD is how long you have to wait to sign up with your employer for LTD insurance, and an ELIMINATION PERIOD is how long you have to wait in order to receive benefits once you file a claim. This is the easiest way to understand the difference.

Most group LTD policies are provided to employees by the employer who may pay all, part, or most of the premium. The employer is considered to be the “policyholder” and the employee is the “certificate holder.” Each employee receives a “certificate booklet” describing the provisions of their LTD policy. Group polices are regulated by the Employment Retirement Income Security Act of 1974. There are some group policies not regulated by ERISA, but these are in the minority. These types of polices are not individually underwritten and the risk is spread out among all members of the insured employer group.

These are individual disability policies, purchased from an agent, which are individually underwritten by the disability insurer. The insurance company assumes all of the risk of any future claims. These polices are not regulated by ERISA.

Nearly all disability polices contain “Life Waiver of Premium” provisions, particularly DI own occupation policies. LWOP provisions set conditions which determine when premiums paid on the policy can be refunded. Most policies require benefits to be approved for total disability in order to receive a refund for premiums paid while claims are under review. In addition, life insurance policies may also contain LWOP provisions for total disability. It’s always a good idea to check both disability and life insurance policies when approved for disability benefits.

In order to be covered by your employer’s group LTD plan you must be IN an eligible group. For example, your policy may say the following: “All full-time employees and salespeople in active employment.” If you are working part-time, you would not be covered. Or, it may say, “All full-time employees with annual basic earning of more than $50,000.” Obviously, if you are a secretary earning $20,000 per year, likewise, you are not covered.

The numbers of hours an employee must be working in order to be eligible to receive benefits. Example: “Employees must be working at least 30 hours per week.” If you go out on claim, and never return to work, you are not eligible to receive benefits on a second claim since you were not working the required number of hours.

A policy which does not allow benefits to be reduced by other income such as SSDI, pensions or worker’s comp.

This wording refers to a condition for “which you received medical treatment, medical advice, care or services including diagnostic measures, or taken prescribed drugs for medicines for your condition during the given period of time as stated in the plan.” The most common of these is the 3/12 pre-existing period condition.
Let’s see how this works. First you find out what the effective date of your policy is. Let’s say it is Jan 1, 2003. One year from this date is Jan 1, 2004. If your date of disability occurs within the time period 1/1/2003 – 1/1/2004, then the insurance company will “go back” three months from the effective date (1/1/2003) to 10/1/2002 and ask you to provide records of treatment from 10/1/2002 to 1/1/2003. This becomes what is called your “pre-ex period”. If you received treatment during this period for the same impairment you are now seeking disability benefits, your claim will be denied.

If you attempt to return to work full time and you are unable to continue within 6 months of doing so, you may go back out on claim without having to meet another elimination period. This information is not often communicated, but it is important if you just can’t work after you thought you could.

All insureds and claimants receiving disability benefits are required to present for in-office consultation and treatment with a frequency reasonably related to the claimed disability. The frequency of treatment is determined by the severity of medical impairment determined by treating physicians. Those receiving disability benefits are expected to remain in “regular care” and be prepared to provide office patient notes which prove “regular care.”

These are manifestations of your condition which you tell your doctor that are not verifiable using tests, procedures or clinical examinations standardly accepted in the practice of medicine. Example of self –reported symptoms include, but are not limited to headaches, pain, fatigue, stiffness, soreness, ringing in ears, dizziness, numbness and loss of energy. The following impairments are often claimed to be self-reported: Fibromyalgia, Chronic Fatigue, Lupus, Multiple Sclerosis, RSD, Lyme disease, Migraine Headaches, Tinnitus, Cognitive Dysfunction, and Depression.

A waiting period is that period of time an employee must wait in order to be eligible to participate in an employer’s group LTD plan. Some policy provisions say: “None”. This means you are eligible to participate in the group plan as of your date of hire. Others require you to wait 30, 60, 90 days, sometimes up to a year before you may sign up to participate in the plan. Generally, you have 31 days to sign up for group LTD insurance once you become eligible. If you miss this deadline, you have to file what is called “Evidence of Insurability” which means your coverage must be underwritten outside of the covered group.