The definition of disability varies from policy to policy, but the traditional definition specifies that total disability is the “inability to work at any gainful occupation” (referred to as “Any Occ”). Under this definition, if the insured can do any job – for even a portion of his former income – the insured is not considered totally disabled. Some older policies require that the insured must also be confined to the house and under the treatment of a doctor. This tightly constructed definition may not be allowed in several states. A more liberal and current definition defines total disability is the “inability to perform the duties of any occupation for which he is reasonably suited by education, training, or experience.” Another definition is “inability to perform all of the substantial and material duties of his regular occupation.” (Referred to generally as “His Occ”)
A typical disability definition states that for a specified time after the beginning of the disability, the insured is totally disabled if he is completely unable to engage in his occupation (His Occ). After the specific time period, commonly one, two or five years, the insured is considered totally disabled only if he is unable to perform the duties of any occupation for which he is reasonably suited by education, training or experience (“Any Occ”).
Partial Disability
Contracts may provide partial disability benefits, particularly in the case of disability caused by accident. Partial disability is often defined as the “inability of the insured to perform one or more of the important duties of his occupation.” Some policies provide that benefits are only payable for a partial disability immediately following a period of total disability for which benefits were payable. The partial disability benefit usually pays a percentage (usually 50%) of the weekly or monthly indemnity payable for total disability for a limited period (usually three to six months).
Policies may provide benefits for residual disabilities. A residual disability benefit provides benefits for loss of earnings after a return to work from total disability, if the insured cannot earn as much as he did prior to the disability. The residual benefit is expressed as a percentage of the amount payable for total disability.
Amount of Benefits
The amount of the weekly or monthly payment applied for is usually based on the insured’s earnings and is usually limited to a percentage of the insured’s earned income. The benefits may be capped (such as: 75% of stated annual income, with a maximum monthly benefit of $5,000).
Special care should always be taken in computing the benefit amount. There can be wide variances in qualifications, and all sources of income must be stated. It should be emphasized that overstating income so that the benefit maximum can be increased, can, at the very least, create an anti-selection element; and can even be grounds for denying benefits at time of disability. Reporting of income vary by company and policy, and the reporting requirements must be stringently followed.
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