If you’re in the process of filing a disability claim, you’re already at major disadvantage trying to figure out what the majority of the terminology means that you’re supposed to read, understand, and respond to. Making sense of what you’re reading is vital in helping you increase the success rate of your disability claim. That’s why in today’s blog, we decided to put together a list of the top basic terms used in long term disability language. Understanding the terminology will not only help make the process easier, but faster as well!

A

Active Work Requirement – To be eligible for disability benefits, you will need to be working at least the minimum number of hours per week as described on your policy prior to stopping work. Some policies require that you perform the material and substantial duties of your regular occupation.

Activities of Daily Living (ADLs) – Routine activities that people tend to do in their everyday life without the need for assistance. There are 5 basic ADLs:

• Eating
• Bathing
• Dressing
• Walking
• Continence

An individual’s ability to perform ADLS plays a big role in determining disability coverage under the terms of the insurance policy.

Adjuster – Someone employed by the insurance company to investigate insurance claims and determine how much the company must pay for the submitted claim.

Appeal – When a long-term disability claim is denied, the insurer will usually require an internal appeal where you must ask for a review of the decision made before filing a lawsuit. The appeal is, in most cases determined by the same company that decided to deny the claim. Some companies will allow up to two total appeals.

B

Bad Faith – Insurance companies are legally bound by a “covenant of good faith and fair dealing” when handling their policyholders. When an insurer is found to breach this covenant by unreasonably delaying or denying payment, it is acting in bad faith.

Beneficiary – A person or entity that is named to receive benefits or proceeds from an insurance policy.

Benefits Period – The maximum amount of time during which your benefits may be paid.

C

Claim – A request for payment under disability insurance plans.

Contributory Plan – A group coverage plan where the costs are shared between the employer and employees.

Cost of Living Adjustment (COLA) – An optional benefit with long term disability plans. It raises the monthly benefits amount each year based on the current cost of living.

D

Declaration Page – The section of a disability insurance company that contains a summary of the coverage along with the limits of the disability insurance provided.

Denial Letter – If your claim gets denied, the claimant will receive a denial letter. This letter is important since it will list what evidence the insurance company reviewed when making its decision. It gives vital information for your appeals, including where and when the appeals must be received.

Disability Appeal – If your claim gets denied, you have the right to appeal and legally challenge the denial in a court of law.

Disability Income – A monthly benefit paid to an individual for a disability covered in the policy covered in the policy provisions in the event of a sickness or accident, to help replace earning lost.

E

Effective Date – The date in which the insurance policy begins.

Elimination Period (Waiting Period) – The elimination (or waiting) period is the time between the date of disability (last day you worked) and the date long term disability benefits may start (day benefits can be payable to you). The disability must continue throughout the entire period to be eligible for long term disability benefits. Elimination Periods are usually between 90 and 180 days.

ERISA – ERISA stands for: Employee Retirement Income Security Act of 1974. ERISA is a federal law that regulates how employee benefit plans are handled. If you challenge a disability denial under an ERISA governed plan/policy, you must bring the claim pursuant to ERISA regulations and procedures. Keep in mind that state law remedies do not apply to an ERISA plan.

L

Long Term Disability Insurance – Long term disability insurance is purchased to provide monthly benefits (income replacement) in the case where you become ill /injured and are unable to work for an extended period of time. You can buy it directly from an insurance provider, or it can be part of your employer-sponsored disability plan – similar to employer sponsored health insurance.

M

Material Duties – The set of skills or tasks required for your specific occupation. These are duties that cannot be reasonably changed without hindering your ability to perform your occupation. These duties are used to help the insurance adjuster determine whether you are disabled.

P

Plaintiff – An individual who initiates a lawsuit in a court of law.

Pre-existing Condition – A medical condition that existed prior to the effective date of the policy where a person has received medical care.

Premium – The periodic payment an individual pays to keep their insurance policy active. Initial premiums are based on:

• Issue age
• Occupation
• Benefit period
• Elimination period
• Monthly benefit amount
• Any optional coverage you select

R

Residual Functional Capacity (RFC) – A claimant’s residual functional capacity is based on what physical level work an individual can perform. The occupational titles are as follows:

• Sedentary: (Ex: office job) where a claimant sits up to six hours a day, stands or walks up to two hours a day, and lifts and carries up to 10 pounds
• Light: (Ex: cashier or security guard) requires that a person be able to stand or walk up to six hours per day and frequently lift and carry 10 pounds and occasionally lift and carry 20 pounds
• Medium: (Ex: nurse or commercial truck driver) requires the ability to lift 50 pounds.
• Heavy: (Ex: Construction) requires the ability to lift up to 100 pounds.
• Very heavy: (Ex: firefighter) requires the ability to lift more than 100 pounds

S

Statute of Limitations – A legal provision setting a time limit during which a person can initiate a legal proceeding. The specific period of time varies based on:

• The type of claim
• The state where a claim is filed

W

Waiver of Premium – As long as benefits are being paid out, no further disability premium payments will be required from people who become disabled and qualify for benefits.

Knowing all the basic long term disability terminology is a start, but there are a lot of things to think about when you’re getting a disability policy. How much coverage will you need to maintain your current lifestyle? Are you getting closer towards the end of your career? What if you’re just starting? At Bonnici Law Group, we can help you better understand all the issues related to your specific situation, do feel free to reach out. We can help guide you with your disability insurance claim so that you can obtain the best results possible! Give us a call at (858) 261-5454 or click here for a free consultation!