In a disability insurance claim, the insurance company and its adjusters typically have a sizable advantage over each claimant. That’s because the adjusters are significantly more familiar with the key terms and provisions in a long term disability insurance policy, or the “language” of disability insurance.
This glossary is intended to help guide you through the most common terms in a disability policy or disability plan. We also encourage you to check out Long Term Disability Insurance Policy Provisions Part I and Part II and our guide to long term disability acronyms and abbreviations. You can also request a free policy evaluation report for a more detailed explanation of the key terms in your unique policy.
Definition of “Disability”
Perhaps the most important thing to know is how the policy defines the terms “disability,” “total disability,” or “totally disabled.” In insurance policies, a disability is typically defined as an injury or illness that prevents an individual from performing the duties of their occupation or perhaps any other occupation. It is important to note that the definition varies from policy to policy, but it typically includes physical and mental impairments that limit or impair an individual’s functioning.
There may be several different categories of the term disability, including:
- Own Occupation
- Any Occupation
- Regular Occupation
- Gainful Occupation
- Split Definition Coverage
- Catastrophic Disability
- Residual or Partial Disability
Insurance policies may define disability differently, but most policies use an “own occupation” or an “any occupation” definition of disability.
An “own occupation” definition of disability typically means that an individual is considered disabled if they cannot perform the duties of their occupation, even if they can perform the duties of another occupation. This can be particularly important for individuals who have specialized skills or training in their profession.
An “any occupation” definition of disability typically means that an individual is considered disabled if they cannot perform the duties of any occupation for which they are qualified, based on their education, training, and experience. This can be a more stringent definition of disability and may make it more difficult for an individual to qualify for benefits.
Most policies we see have an “own occupation” definition of disability for the first two years of payments, and then the definition transitions into an “any occupation” definition.
It is important to carefully review the definition of disability in your insurance policy to understand how it applies to your circumstances.
Here’s another example of how the wording used to define “disability” or “totally disabled” is important. The definition of disability in a long term disability insurance policy may require that the insured person cannot perform “all material duties” of their occupation to qualify for benefits. Other policies may only require that the insured person cannot perform “some material duties.”
If the policy requires the insured person to be unable to perform “all material duties” of their occupation, then they must be completely unable to perform any of the essential duties of their occupation to qualify for benefits.
If the policy requires the insured person to be unable to perform “some material duties” of their occupation, then they may be able to perform some but not all of the essential duties required by their occupation and still qualify for benefits.
I joke that this one-word difference between “all” and “some” is an example of why we need lawyers!
Glossary of Additional Long Term Disability Insurance Policy Terms
“Abilities Claims Consultant”: There are several definitions of an Ability Claims Consultant in a long term disability claim. One definition of an abilities claims consultant is a professional assisting individuals with disabilities in filing claims for disability benefits. A second definition is that an ability claims consultant, or ACC, is the claims handler or insurance adjuster typically responsible for reviewing and LTD claim and issuing a decision on the claim before the start of a lawsuit.
“Active Full-Time Employee”: An active full-time employee is an employee who is working on a regular full-time basis in a position covered by a disability policy. The employee must be actively engaged in performing their duties, have a work schedule consistent with the employer’s expectations, and have an acceptable attendance record. The employee must also meet any eligibility requirements outlined in the disability policy.
“Active Work” Requirement: Active work means performing, with reasonable continuity, the material duties of your own occupation at your employer’s usual place of business. You must be capable of active work the day before your insurance’s scheduled effective date, or your insurance will not become effective as scheduled. If you are not actively at work the day before the scheduled effective date of insurance, your insurance will not become effective until the day after you complete one full day of active work as an eligible employee.
“Activities of Daily Living (ADLs)”: a set of activities related to the basic functioning of an individual’s daily life. These activities are usually divided into instrumental activities of daily living (IADLs) and basic activities of daily living (BADLs). Examples of IADLs include tasks such as grocery shopping, managing finances, and using technology. Examples of BADLs include bathing, dressing, eating, and using the toilet. In a disability policy, ADLs are used to assess an individual’s level of independence and need for assistance. This assessment helps to determine eligibility for disability benefits, such as those provided by the Long Term Disability Insurance Company.
“Actual Damages”: a type of compensation awarded to a plaintiff in a lawsuit. They are intended to make the plaintiff whole by replacing what was lost as a direct result of the defendant’s wrongful conduct. Actual damages are intended to make the plaintiff “whole” by restoring them to the position they would have been in had the defendant not acted wrongfully. Examples of actual damages in an LTD claim include past-due disability insurance benefits.
“Adjuster”: An adjuster is a professional employed by an insurance company to investigate and evaluate disability insurance claims. They will review the claim and determine the claimant’s eligibility for disability insurance benefits.
“Annualization of Waived Premium”: If the policy premium payment date falls when premiums are being waived, then the entire year of premiums will be waived.
“Any Occupation”: Any Occupation is a provision in disability insurance policies that allows an insurance company to deny a claim for disability benefits if the claimant can perform the duties of any occupation for which he or she is reasonably suited by education, training, or experience. The insurer may deny a claim if it demonstrates that the claimant can do other work, even if it is not the same job they did before they became disabled.
“Appropriate Care”: “Appropriate care” in a disability policy refers to the medical care and treatment a disabled claimant or beneficiary must receive to qualify for disability benefits. In most disability policies, the claimant must be under the care of a licensed medical professional and receive appropriate medical treatment for their disability to receive benefits. The specific requirements for appropriate care can vary depending on the type of disability, the policy terms and conditions, and the treating physician’s recommendations. Appropriate care requires that the claimant receives ongoing medical treatment consistent with the standard of care for their particular disability.
“Attending Physician Statement, or APS”: The Attending Physician Statement is a document completed by the claimant’s physician and submitted as part of a disability insurance claim. This statement provides important information about the claimant’s medical condition, including diagnosis, prognosis, treatment plan, and any limitations or restrictions that may affect the claimant’s ability to work. The Attending Physician Statement is an essential part of the disability claim process, as it provides the insurance company with the necessary medical information to make an informed decision on the claim.
“Automatic Increase Rider”: This rider increases the insured’s total monthly benefit each year for about five years. This rider applies without regard to health, income, or occupation changes.
“Bad Faith”: A situation where an insurance company denies a valid claim made by a claimant without a reasonable basis or fails to investigate and process a claim promptly and fairly properly. Essentially, it means that the insurance company is not acting in good faith towards the claimant and instead prioritizing its financial interests over the needs of the person making a claim.
Examples of bad faith insurance practices might include unjustified claim denials, unreasonable delays in processing claims, or offering a significantly lower settlement than the claimant is entitled to receive. In some cases, bad faith insurance practices can lead to legal action against the insurance company by the affected claimant (see next definition). However, bad faith claims may not be available in most ERISA disability insurance claims.
“Bad Faith Lawsuit”: A lawsuit against an insurance company for Bad Faith (see above definition). To prove bad faith, the plaintiff must demonstrate that the insurance company had no reasonable basis for its actions and acted with intentional or reckless disregard for the claimant’s legal and contractual rights. This can include failing to investigate a claim properly, denying a claim without providing a valid reason, or failing to communicate with the claimant promptly and transparently. If successful, a bad faith lawsuit can result in significant damages for the claimant, including compensation for any financial losses resulting from the insurance company’s actions and punitive damages to deter similar behavior.
“Beneficiary”: An insurance beneficiary is a person or entity who receives the benefits of an insurance policy in an event that triggers the policy’s coverage. The beneficiary is typically designated by the claimant when the policy is purchased or updated. The insurance policy outlines the conditions under which the beneficiary will receive the benefits. In a disability insurance claim, that typically means regular payments over a certain period. The beneficiary is typically responsible for providing proof of eligibility for benefits and may need to submit a claim to the insurance company to receive the benefits.
“Benefit Period”: A benefit period in insurance refers to the length of time an insurance claimant is eligible to receive benefits for a covered claim. This period varies depending on the specific terms of the policy. For example, in long term disability insurance, a benefit period might refer to the length of time during which a claimant is eligible to receive disability benefits if they are unable to work due to a covered disability.
The benefit period is typically defined in the insurance policy and can range from a few weeks to retirement age, depending on the type of policy and the specific terms of coverage.
“Benefit Percentage”: The amount payable to the insured, based on a percentage of the insured’s income before becoming disabled. The benefits are typically limited to an overall maximum amount.
“Catastrophic Disability”: a severe and permanent impairment that significantly impacts an individual’s ability to perform daily activities and requires extensive medical and rehabilitative care. This type of disability often results from a sudden and traumatic event, such as a severe accident or injury, and can include spinal cord injuries, traumatic brain injuries, severe burns, amputations, and other serious medical conditions.
“Chess”: CHESS is an acronym for Chronic Pain, Hardship, Emotional Distress, and Social Security, which are four factors that may be considered in a long term disability claim.
“Claim”: A disability claim is a request for benefits made by an individual unable to work due to a physical or mental impairment. A disability claim can be made under a group disability insurance policy or an individual policy.
“Classes of Coverage”: Classes of coverage in a disability policy typically refer to the different types of coverage offered to individuals within a group or organization.
For example, an employer may offer disability insurance to its employees with different classes of coverage based on factors such as job title, salary, or length of employment. The coverage classes may determine the coverage available to each employee, the premium cost, and other terms and conditions.
Some common classes of coverage in a disability policy may include:
- Non-contributory coverage: This is coverage provided by the employer without any contribution required from the employee.
- Contributory coverage: This is coverage provided by the employer but with a portion of the premium cost paid by the employee.
- Voluntary coverage: This is coverage offered to employees on an optional basis, with the entire premium cost paid by the employee.
- Executive coverage: This may be provided to high-level executives or key employees with higher benefit levels and other special features.
The specific coverage classes available in a disability policy may vary depending on the insurer and the employer’s plan design.
It is important to understand that the policy may have different coverages and requirements for each different class of employees.
“Commensurate Amount”: Many long term disability insurance policies will specify the amount of compensation that would make a comparable occupation “commensurate” or “gainful.” The percentage varies from policy to policy, but the “commensurate amount” is often 60% of the claimant’s pre-disability income.
“Contributory Plan”: A contributory plan in insurance is a type of insurance plan in which both the employer and the employee contribute to the plan’s cost. In a contributory plan, the employee pays a portion of the premium for the insurance coverage, usually through payroll deductions, and the employer also pays a portion of the premium. Contributory plans are commonly used in employer-sponsored group insurance plans such as disability insurance.
“Conversion Privilege”: The right of an insured to convert benefits under a group long term disability insurance policy to an individual policy without requiring a physical examination to give proof of insurability.
“Cost Of Living Adjustment (COLA)”: In insurance, this refers to an increase in the benefit amount of an insurance policy to keep pace with inflation and rising living costs. A COLA is typically applied to many long term disability insurance policies but is subject to the policy’s specific terms. With a COLA provision, the benefit amount of an insurance policy will increase annually based on a predetermined formula that considers changes in the cost of living or inflation. This ensures that the benefit amount keeps pace with rising expenses and provides consistent coverage.
“Declaration Page”: A declaration page on a disability insurance policy is a document that summarizes the key information about the policy. It is typically toward the front of the policy and contains important information such as the policyholder’s name and address, the policy number, the effective date of the policy, the coverage limits and options, the elimination period, and any exclusions or limitations that may apply.
“Deductible Sources of Income”: Deductible sources of income in a disability claim are sources of income that are subtracted from the disability benefit amount that a claimant is eligible to receive. Common deductible sources of income in disability claims may include: (1) Social Security Disability Insurance (SSDI) benefits; (2) Workers’ compensation benefits; (3) Pension benefits; (4) Other disability or retirement benefits, such as VA benefits; and (5) third party liability payments. The specific types of deductible sources of income can vary depending on the terms and conditions of the disability insurance policy.
“Denial Letter”: A long term disability denial letter is a written communication from an insurance company to an LTD claimant, stating that their claim for long term disability benefits has been denied. This letter outlines why the claim was denied and may provide information on how to appeal the decision. Typically, the denial letter will explain the specific criteria the claimant did not meet the requirements to qualify for benefits. This may include information about the policy terms and conditions and any medical evidence or other documentation submitted with the claim.
“Disability Appeal”: An appeal in a long term disability claim is a process by which a claimant challenges the denial of their claim for long term disability benefits. When an insurance company denies a long term disability claim, the claimant can appeal the decision and provide additional evidence or information to support their claim. The appeals process typically involves submitting a written request to review the denied claim and providing any new or additional information that may support the claim. The insurance company will review the appeal and decide whether to overturn or uphold the original denial.
“Disability Income”: Disability income is a type of insurance benefit that provides financial support to individuals who cannot work due to a disability or illness. Disability income insurance policies are designed to replace a portion of the claimant’s income if they become disabled and cannot work for an extended period. The amount of disability income insurance benefits a claimant can receive depends on the terms of their policy. Some policies cover a specific percentage of the claimant’s income, while others provide a fixed amount of monthly benefits.
“Discretionary Clause”: Discretionary clauses are provisions in an LTD insurance policy that allow the insurance company to interpret the policy and make decisions about the claim.
“DMAP”: DMAP stands for Disability Management Action Plan, a plan developed by the insurance company or employer in a long term disability claim to help an individual return to work after a disability.
“Effective Date” of Policy: The effective date of an insurance policy is the date on which the policy becomes active and the coverage under the policy begins. It is the date that the insurance company assumes responsibility for providing coverage to the claimant in exchange for payment of the premiums.
“Effective Date” of Benefits: The effective date in a disability claim is when the insurance company determines that the claimant became disabled and eligible for benefits. This date is important because it determines when the claimant is eligible to start receiving benefits and how much they are entitled to receive.
“Elimination Period” (also called a “Waiting Period”): In a long term disability insurance claim, the elimination period is the initial waiting period before the claimant becomes eligible to receive benefits. It is the period of time between the onset of the disability and the start of the insurance company’s payment of benefits. The claimant must remain continuously disabled through the end of the elimination period to begin receiving benefits. The elimination period for long term disability insurance policies is typically longer than for short term disability policies and can range from 30 to 365 days, depending on the policy terms and conditions.
“ERISA”: ERISA disability refers to disability insurance governed by the Employee Retirement Income Security Act of 1974 (ERISA). This law establishes minimum standards for employer-sponsored benefit plans, including long term disability plans. Most LTD plans offered by private companies (non-governmental or church employers) are subject to ERISA regulations. If you go through the appeals process for a claim governed by ERISA, you must follow ERISA regulations and procedures. ERISA “pre-empts” state law, so state law remedies do not apply to ERISA claims.
“Exclusions”: Exclusions in a long term disability claim refer to the specific circumstances or conditions not covered by the insurance policy. These exclusions can vary depending on the specific policy, but typically they include (1) Pre-existing conditions; (2) Self-inflicted injuries; (3) Criminal activity; (4) War or acts of terrorism; and (5) Substance abuse. This is a sample list and may not be exhaustive.
“Forecast Date”: A forecast date in a long term disability claim is an estimate of when an individual may be able to return to work following a period of disability.
“Functional Capacity Exam (FCE)”: A functional capacity exam, or FCE for short, is a comprehensive evaluation of an individual’s physical and functional abilities and is designed to assess their physical limitations, endurance, and functional abilities related to their work or occupation.
“Functional Telephone Interview”: A functional telephone interview may refer to a phone call between the disability insurance company and the claimant (the person claiming disability benefits).
“Gainful Employment“ or “Gainful Occupation”: Gainful occupation is typically defined as an occupation for which the claimant is reasonably qualified because of his or her physical and mental capacity, education, experience, and training, as well as training he or she could receive. This typically applies in the “any occupation” period of the disability claim. Some policies may more specifically define the term “gainful occupation.” For example, under one policy found online, gainful occupation means the claimant could reasonably be expected to earn at least as much as the LTD disability insurance benefit amount (or some other defined percentage of the claimant’s pre-disability income).
“Group Coverage”: Group coverage in the context of long term disability insurance refers to an insurance policy that provides disability coverage to a group of individuals, typically employees of a company or members of an association. When an individual covered under a group LTD policy becomes disabled and cannot work, they may be eligible to receive benefits under the group policy.
“Health Management Consultant”: A health management consultant in the context of a long term disability claim is a professional hired by the disability insurance company to help manage the medical aspects of the claimant’s case. The consultant may be a medical doctor, nurse, or other healthcare professional with expertise in managing long term disability claims.
“Individual Disability Insurance (IDI)”: Individual disability insurance is a type of insurance policy that provides income replacement benefits to an individual if they become disabled and cannot work. Unlike group disability insurance, which is typically provided as an employee benefit, individual disability insurance policies are purchased by individuals directly from insurance companies.
“Insured”: In a disability insurance policy, the term “insured” typically refers to the person covered under the policy and eligible to receive benefits in the event of a covered disability. The insured is the individual who has applied for and been approved for coverage under the policy. The policy will specify the conditions under which the insured may become eligible for benefits, including the definition of disability, the waiting period before benefits become payable, the benefit amount, and the benefit period.
“Long Term Disability Insurance”: Long term disability insurance provides income replacement benefits to individuals who cannot work for an extended period due to a covered disability. In the event of a covered disability, LTD insurance provides a percentage of the individual’s pre-disability income, typically ranging from 50% to 70%, for a specified period of time, such as two, five, or ten years, or until the individual reaches retirement age. The benefit period and amount vary depending on the terms of the policy.
“Lump Sum Payment”: A lump sum payment in disability insurance refers to a one-time payment made to the insured in lieu of ongoing monthly benefit payments. Instead of receiving a monthly benefit payment for a specified period of time, the insured receives a single payment that represents the present value of the future benefit payments. Some disability insurance policies may offer the lump sum payment option as an alternative to receiving monthly benefit payments.
“Material Duty” or “Material Duties”: A “material duty” typically refers to a job duty or function that is essential to the performance of the insured’s occupation. When evaluating a disability claim, the insurance company will typically assess the insured’s ability to perform the material duties of their occupation. This assessment may involve reviewing the insured’s job description, consulting with the insured’s employer or healthcare providers, and conducting functional capacity evaluations or other assessments to determine whether the insured can perform the essential duties of their occupation.
“Maximum Capacity”: In a long term disability claim, “maximum capacity” typically refers to the highest level of physical or mental functioning that an insured is capable of achieving based on medical evidence, vocational assessments, and other relevant factors.
“Maximum Monthly Benefit”: In a long term disability claim, the “maximum monthly benefit” refers to the highest monthly disability benefits an insured can receive under their disability insurance policy.
“Member of an Eligible Group”: A “member of an eligible group” typically refers to an individual eligible to participate in a group long term disability insurance plan offered by an employer or other organization.
“Mental Health Limitation”: A mental health limitation in a long term disability claim is a restriction or limitation on the benefits an insured can receive for a mental health condition, such as depression, anxiety, or post-traumatic stress disorder (PTSD). These limitations may include: (1) a cap on how long the claimant may receive benefits (such as 24 months); (2) limits on the amount of monthly benefits; or (3) exclusions for certain mental health conditions.
“Minimum Monthly Benefit”: In a long term disability policy, the “minimum benefit” refers to the lowest monthly benefit amount an insured is entitled to, regardless of the offsets for other income benefits. If there is such a provision in the policy, it ensures that the claimant will receive at least some monthly benefits.
“Minimum Hours Requirement”: A minimum hours requirement typically refers to the number of hours an individual must work to be eligible for disability benefits. This requirement is included in the policy terms and conditions. For example, a policy may require that an individual work at least 30 hours per week to be eligible for disability benefits.
“Non-Contributory Plan”: In a long term disability plan, a non-contributory plan is a group disability insurance plan where the employer pays the entire cost of the disability insurance premiums on behalf of its employees.
“Non-Exertional Limitations”: Non-exertional limitations refer to physical or mental restrictions or limitations that affect an individual’s ability to work but do not relate to their ability to lift, carry, push, or pull objects or perform other physical tasks.
“Non-Integrated Policy”: A non-integrated policy does not consider any other sources of income that the individual may be receiving, and the disability benefits are paid out based solely on the terms of the policy. In other words, the benefits under a non-integrated policy are not reduced by the amount of other sources of income that the individual is receiving, such as Social Security Disability Income or pension benefits.
“Offset”: An “offset” refers to a policy provision allowing the insurer to reduce the benefits paid to the policyholder by any other sources of income the policyholder may be receiving.
“Own Occupation”: “Own occupation” in a long term disability claim refers to a type of disability insurance policy that defines disability as the inability to perform the duties of one’s own occupation. Under this type of policy, a policyholder is considered disabled if they cannot perform the duties of the occupation they were engaged in at the time of becoming disabled, even if they can perform other types of work.
“Plaintiff”: In a lawsuit, the plaintiff is the person who brings a legal action against another party, known as the defendant. The plaintiff is typically the party claiming to have suffered harm or injury due to the defendant’s actions or failure to act and is seeking a legal remedy, such as monetary damages or an injunction. In a long term disability insurance breach of contract case, the plaintiff is the claimant who did not receive the disability insurance benefits promised in the contract, while the defendant would be the disability insurance company who failed to pay them.
“Policy”: A disability insurance policy provides income replacement benefits to individuals if they become disabled and cannot work. Disability insurance policies can be purchased by individuals or provided by employers as part of a benefits package. It is a legal agreement between an insurance company plan and the individual or group. It lists the terms and conditions of the plan’s coverage.
“Policyholder”: A policyholder is a person or entity that owns an insurance policy. They are the individual or organization that has entered into a contractual agreement with an insurance company, whereby the insurance company agrees to provide financial protection against specified risks or losses in exchange for a premium payment. In a disability claim, the policyholder can be the person whose work income is being insured. The policyholder has certain rights and responsibilities under the insurance policy’s terms, including the obligation to pay premiums and comply with any policy conditions or requirements.
“Portable Coverage”: Portable coverage in a disability policy refers to a type of insurance policy that allows the policyholder to continue their disability coverage even if they change jobs or leave their current employer. Typically, disability insurance policies are provided by employers as part of their benefits package, and the coverage ends when the employee leaves the company. However, with portable coverage, the policyholder can maintain their disability insurance policy even if they move to a new employer, start their own business, or become self-employed.
“Pre-Existing Condition”: A pre-existing condition is a health condition or medical problem that existed before an individual enrolled in a long term disability insurance policy. In the context of a long term disability claim, a pre-existing condition can affect an individual’s eligibility for benefits or the terms of their coverage. Insurance companies often define pre-existing conditions as illnesses or injuries for which the individual received medical treatment, consultation, or advice within a specified period before enrolling in the policy. This period is usually called the “look-back period,” it varies by insurer but is typically between three and six months.
“Pre-Existing Condition Exclusionary Period”: A pre-existing condition exclusionary period is a waiting period that an individual must satisfy before becoming eligible for benefits under a long term disability policy. The exclusionary period applies to pre-existing conditions, defined as health conditions or medical problems that existed before the individual enrolled in the policy. During the exclusionary period, the insurer will not provide coverage for disabilities caused or contributed to by the pre-existing condition. The length of the exclusionary period varies by insurer but is typically between 3 and 12 months.
For example, if an individual has a pre-existing condition such as back pain and becomes disabled due to a back injury during the exclusionary period, the insurer will likely deny the claim for benefits. However, if the individual becomes disabled due to an unrelated illness or injury during the exclusionary period, they may be eligible for benefits.
“Pre-Existing Condition Limitation”: A limitation requiring a specified “treatment-free period” or period of time the claimant must be insured for known medical conditions to be covered under the policy.
“Pre-Disability Earnings”: Pre-disability earnings in a long term disability claim refer to the income an individual earned before they became disabled and unable to work. Pre-disability earnings are crucial in determining an individual’s benefits under a long term disability policy.
“Premium”: In the context of a long term disability claim, a premium refers to an individual’s payment to the insurance company to maintain their long term disability coverage. The premium is the cost of the policy and is typically paid monthly, quarterly, or annually.
“Punitive Damages”: Punitive damages in a long term disability claim refer to damages awarded to an individual as a form of punishment to the insurance company for misconduct or egregious behavior. Punitive damages are not awarded in every long term disability case, and they are usually only awarded in cases where the insurer’s conduct is considered particularly reprehensible.
“Qualifying Period”: See the definition of the elimination period above.
“Rate of Benefit”: A rate of benefit in a long term disability claim refers to the amount of money an individual will receive in disability benefits from the insurance company. The rate of benefit is determined by the terms of the long term disability policy, which sets out the percentage of the individual’s pre-disability income that will be paid out as benefits.
“Reasonable Accommodation”: Any modifications to the employee’s worksite, the job, or employment practices, that would allow the insured claimant to perform the material duties of the occupation and would not create an undue hardship for the employer. For example, a modified workstation or adaptive work equipment.
“Recurrent Disability”: A recurrent disability in a long term disability claim refers to an individual who has previously received long term disability benefits experiencing a recurrence of their disabling condition. In this context, a recurrent disability may be covered under the terms of the long term disability policy, allowing the individual to resume receiving benefits.
“Recurrent Provision”: A recurrent provision is a clause or provision that may be included in a long term disability insurance policy. This provision applies in cases where an insured individual has returned to work after a period of disability but subsequently experiences a recurrence of the same or related medical condition that caused the initial disability.
“Regular Care”: Regular care in a long term disability claim refers to the ongoing medical treatment and attention that an insured individual must receive to manage and treat their disabling condition. In most long term disability insurance policies, there is a requirement that the insured individual is under the regular care of a physician to be eligible for disability benefits.
“Rehabilitation Benefits”: Rehabilitation benefits in a long term disability claim refer to benefits that are provided to an individual to help them recover from a disability and return to work. Rehabilitation benefits may be included as part of a long term disability policy and may be available in addition to disability benefits.
“Residual Disability” or “Partial Disability”: Residual disability in a long term disability claim refers to a situation where an individual can still work, but their ability to perform their job duties has been reduced due to a disabling condition. In this context, residual disability benefits may provide partial compensation for the loss of income due to the reduced ability to work.
“Residual Functional Capacity”: Residual functional capacity (RFC) in a long term disability claim refers to the individual’s ability to perform work-related activities despite their impairments or limitations resulting from a medical condition. In other words, it measures what an individual can still do rather than what they cannot do.
“Rescission”: Rescission in a long term disability claim is the act of canceling or voiding a disability insurance policy retroactively, meaning the policy is considered null and void from the policy’s start date. Rescission may occur when the insurer discovers that the insured provided false or misleading information during the application process, which would have affected the insurer’s decision to approve the policy or the terms of coverage.
“Rider”: In the context of a long term disability claim, a rider is an additional provision or amendment to a disability insurance policy that modifies or enhances the coverage provided under the policy.
“Salary Percentage Requirement”: A salary percentage requirement is a common feature of long term disability insurance policies that specifies the amount of income an insured individual must have lost to be eligible for disability benefits.
“Schedule of Benefits”: A schedule of benefits is a document that outlines the amount and duration of benefits that an insured individual is eligible to receive under a long term disability insurance policy.
“Self-Reported Symptoms”:
Symptoms that are self-reported by the claimant and that are not easily validated by objective testing. Examples may include environmental allergic illness, chronic fatigue syndrome, fibromyalgia, etc.
“Self-Reported Symptoms Limitation”: A self-reported symptoms limitation is a provision in some long term disability insurance policies that limits the amount of benefits that an insured individual can receive for disabilities that are based solely on self-reported symptoms, such as pain or fatigue, rather than on objective medical evidence, such as diagnostic tests or imaging studies.
“Short Term Disability” or “STD”: Short term disability insurance is a type of insurance policy that provides income replacement benefits for a limited period of time when an insured individual cannot work due to a covered disability or illness.
“Split Definition Coverage”: Split definition coverage is a type of long term disability insurance policy that uses two different definitions of disability to determine whether an insured individual is eligible for benefits. The first definition is an “own occupation” definition, which defines disability as the inability to perform the material duties of one’s own occupation. The second definition is an “any occupation” definition, which defines disability as the inability to perform the material duties of any occupation for which the insured individual is reasonably qualified based on education, training, or experience.
“Statute of Limitations”: The statute of limitations in a long term disability claim is the time limit within which an individual must file a claim or a lawsuit seeking disability benefits under their policy. The statute of limitations varies depending on the jurisdiction and the specific terms of the insurance policy.
“Terminated”: If you were receiving long term disability insurance benefits from an insurance company and the payments are cut off, then the benefits have been terminated. You may have the right to file an appeal or lawsuit after your benefits are terminated.
“Toll” or “Tolling”: When an insurance carrier “tolls” its decision on a claim, they are extending their allowed time frame to issue a decision. Basically, the insurer is not ready to decide your claim and is delaying its decision.
“Total Disability”: This will be defined in the disability policy. It defines the parameters used to determine if an employee is eligible for benefits because of a physical or mental illness or injury. There may be several levels to this definition:
- Own Occupation: Disability is initially determined by whether an employee can still perform the duties of his or her own job. If the insured cannot do his usual work, he or she may qualify for benefits. Insurance companies may use generalized job descriptions when evaluating an occupation’s physical and mental demands. This provision lasts just a short period of one, two, or five years. After that, the policy may become more restrictive under an “any occupation” provision.
- Any Occupation: Under this definition of disability, the insured will be considered disabled if he or she cannot work in any occupation he or she is qualified for by education, training, or experience.
“Underwriter”: An underwriter in a long term disability claim is an individual or a company responsible for evaluating and assessing the risks associated with insuring an individual’s disability. In a long term disability insurance policy, the underwriter is responsible for setting the terms and conditions of the policy, including the benefit amount, the elimination period, and any exclusions or limitations. The underwriter also determines the premium rate for the policy based on the individual’s age, occupation, medical history, and other risk factors.
“Vocational Expert”: A Vocational Expert (VE) in a long term disability claim is a professional who evaluates an individual’s work-related abilities and limitations in the context of their disabling medical condition. The VE provides an opinion on whether the individual can return to their occupation or any other occupation, and if so, what type of job is suitable given their medical condition.
“Vocational Review”: A vocational review in a long term disability claim evaluates an individual’s vocational skills, work history, and employment opportunities in the context of their medical condition. A vocational review aims to determine whether the individual can perform their occupation or any other occupation, given their medical condition and any resulting limitations or restrictions.
“Voluntary Plan” or “Employee-Paid Plan”: A voluntary plan in a long term disability (LTD) plan is a type of group LTD insurance plan that is offered by an employer but is entirely funded by employees through payroll deductions. Voluntary plans allow employees to purchase LTD coverage at a group rate, typically less expensive than purchasing individual coverage.
“Waiting Period”: A waiting period, also known as an elimination period, in a long term disability claim, refers to the period an insured person must wait after becoming disabled before they become eligible to receive benefits under their policy. The waiting period is a common feature of most long term disability insurance policies and is typically expressed in terms of a specific number of days, such as 30, 60, or 90 days.
“Waiver of Premium”: A waiver of premium in long term disability insurance is a provision that relieves the insured person from paying their monthly premiums for the policy if they become disabled and unable to work. This provision is typically included in most long term disability insurance policies.