Contract Provisions, Definitions, and Benefits

Question 1

Contract

Answer 1

A legal agreement between the Employer (also known as the Policyholder or Group) and the insurance company which outlines what coverage will be extended to eligible employees and under what conditions. Can be one or all of the following: Application/Subscription Agreement, Certificate, or Policy.

Question 2

Plan

(ERISA)

Answer 2

A program to provide benefits.

Question 3

Participating Unit

Answer 3

Participating Unit means any sole proprietorship, partnership, corporation, limited liability company, limited liability partnership, firm, school district, individual school, or other instrumentality of a state or political subdivision thereof, that has been approved by AUL and added by amendment to the Group Policy.

Question 4

Policyholder

(PH)

Answer 4

The entity with whom OneAmerica has entered into an insurance contract.

Question 5

Policyholder Name

(Group Name)

Answer 5

This is the name of a specific customer.

Question 6

Policyholder Number

(Group number)

Answer 6

This is the number used to identify a customer.

Question 7

Employer

(ER)

Answer 7

The entity or organization for which the Person performs services and which has the right to control what will be done, and how it will be done. An Employer has the right to control the details of how the services are performed by the Person. The Person must not be considered an independent contractor or agent unless classified by the IRS as a statutory employee of the Employer. The Employer is the entity or organization for which the Person performs his occupation, and is required to withhold and pay income, social security, and Medicare taxes on wages.

Question 8

Insured

Answer 8

A person covered under a group insurance contract.

This is not necessarily always group contract, but for AUL, it is.

Question 9

Prudent Person

Answer 9

An individual who uses good judgment or common sense in handling practical matters.

Question 10

Employee

(EE)

Answer 10

A person employed by a company/person who puts in a claim for benefits.

Question 11

Initial Employee

Answer 11

An employee hired before the Policyholder or coverage effective date.

Question 12

Effective Date

Answer 12

The date that a coverage is in-force or employee is covered under the group contract.

Question 13

Waiting Period

(WP)

Answer 13

The amount of time a person must be actively at work prior to becoming eligible for coverage.

Question 14

Initial Enrollment Period

Answer 14

Time period when initial employee’s enrolled for coverage and during which new employees have to enroll for coverage without Evidence of Insurability.

Question 15

Scheduled Enrollment Period

Answer 15

A period of time each year when employees can change their coverage or apply for coverage if they are late enrollees.

Question 16

Late Enrollee

Answer 16

An employee who did not elect coverage during the initial enrollment period.

Question 17

Evidence of Insurability

(EOI)

Answer 17

A statement or proof of an Employee’s medical history upon which eligibility for insurance will be determined by AUL. EOI may be required for late enrollees, increase of elected benefit or other reasons as defined by the Policy. Coverage will be approved or declined by medical underwriting. See AWD for letter confirming effective date of coverage.

Question 18

Statement of Insurability

(SOI)

Answer 18

A form that must be completed when Evidence of Insurability (EOI) is required. EOI and SOI are sometimes used interchangeably to describe this form. The form contains questions about a person’s current and previous medical history and health.

Question 19

Family Status Change

Answer 19

A change in your situation (e.g. such as marriage, child birth, etc.) that can make you eligible for a Special Enrollment Period, allowing you to enroll in insurance outside the yearly Open Enrollment Period.

Question 20

Certificate

Answer 20

A document containing contractual information outlining the benefits elected by the Policyholder.

Question 21

Certificate Number

Answer 21

The number assigned to the Certificate

Question 22

Class

Answer 22

A well-defined segment of the covered group that has been separated according to specific criteria.

Question 23

Closed Class or Plan

Answer 23

A class that has employees enrolled, but no future enrollment into that class. A closed class is typically to accommodate a particular situation, i.e., grandfathered employees, employees from a takeover that may have a different benefit, etc.

Question 24

Elected Benefit

Answer 24

The benefit amount is not based on salary. It’s either a true flat amount (one for everyone) or an incremental amount.

Question 25

Coverage Month

(Policy Month)

Answer 25

The period of time beginning on the Person’s Individual Effective Date, and continuing from the first day and ending on the last day of each succeeding Policy Month.

Question 26

Schedule of Benefits

Answer 26

This is a summary of benefits that appears after the table of contents of each certificate and Policy. A Policy contains all Schedule of benefits page for all classes for a particular coverage.

Question 27

Actively at Work

Answer 27

A defined term under the OA Disability Policy. It is considered for purposes of whether/when an individual is covered under the Policy. Generally, this refers to a period of time that an individual is physically at work, however, may include instances such as when someone is on Paid Time Off or approved leave under the Family Medical Leave act (FMLA) as outlined in each Policy.

Question 28

Amendment

Answer 28

A legal document changing the provisions of the Policy that is signed jointly by the insurance company and an authorized representative of the policyholder.

Question 29

Rider

Answer 29

An optional coverage of feature that can be added to coverage (generally at an additional cost).

Typically, Riders can be located in the policy’s Schedule of Benefits (see definition). Examples: COBRA, Supplemental Disability Benefit, Social Security Incentive, Survivor Benefit, etc.

Question 30

Continuity of Coverage

Answer 30

A provision sometimes offered in a Policy where an OA Policy takes over from another carrier and is an exception and/or taken into consideration with the pre-existing condition exclusion or limitation, if a claimant had coverage with the Long-Term Disability prior their employer had, prior to OneAmerica.

Question 31

Conversion

Answer 31

A provision in the insurance Policy that allows individuals who through termination are no longer eligible for coverage under the group Policy, to convert to an individual plan of insurance without providing evidence of insurability.

Question 32

Portability

Answer 32

A provision under some policies which allows employees to take the coverage with them upon termination of employment.

Question 33

Guaranteed Issue

(GI)

Answer 33

The maximum amount of coverage allowed without Evidence of Insurability (EOI).

Question 34

Guaranteed Increase in Benefit

(GIB)

Answer 34

The amount of coverage that does not require Evidence of Insurability (EOI). This amount is shown on the Schedule of Benefits page. Of note, although no EOI required, with increased election, the GIB, may be subject to pre-existing review. Each Policy will outline parameters regarding this.

Question 35

Special Conditions Limitations

Answer 35

A policy provision that applies when chosen by the Participating Unit on the Subscription Agreement. Benefits for Disability due to Special Conditions, whether or not benefits were sought because of the condition, will not be payable beyond a number of months as defined by the Policy and is also stated on the Subscription Agreement. Benefits payments for Disabilities due to Special Conditions are cumulative for the lifetime of the contract.

Question 36

Waiver of Premium

(WOP)

Answer 36

A provision that allows the insured to not pay premiums under certain circumstances set forth in the Policy.

Question 37

Accidental Dismemberment & Loss of Sight

Answer 37

A benefit offered in OA Disability group coverages that requires certain conditions (e.g., loss of limb or sight) to be entitled.

Question 38

Advance Survivor Benefit

Answer 38

Provision in some policies that generally allows a Person to receive an Advanced Survivor Benefit prior to the Person’s death if he has been diagnosed with a Terminal Illness, while covered under the Group Policy, in lieu of any other Survivor Benefit under the Group Policy upon the Person’s death.

Question 39

Family Care Benefit

Answer 39

A benefit provision offered under the Plan. Under certain circumstances as defined in the Plan, an additional benefit will be paid for costs associated with family care.

Question 40

Franchise Coverage

Answer 40

Disability insurance coverage which allows Employees to be insured as part of their relationship with the Policyholder but such coverage is not part of an employee welfare benefit plan and the Employees are insured under individual policies.

Question 41

Accident

Answer 41

Generally, an unforeseen unintended event. Most times defined in a Disability Policy with “Injury.” Injury means a bodily injury resulting directly from an accident and that occurs independently of all other causes.

Question 42

Partial Disability

Answer 42

A defined Term under a disability policy when a claimant is unable to perform their occupation full time and full duty based on impairment, however, is able to work in some capacity at their own occupation or in another occupation.

Not all policies include partial disability and total disability.

Question 43

Accumulated Sick Leave

Answer 43

The number of sick days accrued by an employee as a part of their employer’s sick leave Policy.

Question 44

Regular Job

Answer 44

The Claimant’s own job of which they are unable to perform based on their impairment.

Question 45

Regular Occupation

Answer 45

The Claimant’s own occupation of which they are unable to perform based on their impairment.

Question 46

Date of Disability

Answer 46

The date a person becomes disabled as defined by the Plan, typically, this is usually the date the elimination period begins.

Question 47

Last Day Worked

Answer 47

The last day an employee was actively and physically at work. This is used in determining things such as when coverage terminates, and in determining eligibility for benefits such as claims, continuation, portability, and conversion.

Question 48

Elimination Period

(EP)

Answer 48

A defined term under the Policy. Generally it is a period of time that a person must be totally disabled or partially disabled under the terms of the Policy, and for which benefits are not paid.

Question 49

Full-Time Hours

Answer 49

The minimum number of hours an employee must work in order to receive benefits. This is determined by each Policyholder for each coverage and defined in the Schedule of Benefits in the Policy.

Question 50

Covered Earnings

Answer 50

The amount of an employee’s pay that accounts toward the calculation of disability benefits as defined by the Policy.

Question 51

Benefit Amount

Answer 51

This is the amount an insured would receive if they were approved for a claim.

Question 52

Benefit Duration

Answer 52

The length of time, as defined in in the Policy, during which a benefit is paid.

Question 53

Maximum Benefit Duration

Answer 53

The maximum amount of time a benefit is payable to an insured person as defined by the Plan documents.

Question 54

Benefit Maximum

Answer 54

The maximum amount allowed in the plan design for any insured.

Question 55

Benefit Minimum

Answer 55

The minimum benefit amount allowed in the plan design for any insured.

Question 56

All Sources Integration

Answer 56

A provision offered in some policies where Other Income Benefits are calculated to provide the claimant with a net benefit higher than a direct dollar for dollar offset.

Question 57

Annual Increase in Benefit

(AIB)

Answer 57

An additional amount of coverage that may be available to a Person annually if certain specified conditions are met, outlined by each Policy.

Question 58

Total Disability

Answer 58

Generally, Total disability or totally disabled means that because of Injury or Sickness a Person is under the Regular Attendance of a Physician for that Injury or Sickness; is not working in any occupation; and cannot perform the Material and Substantial Duties of his Regular Occupation.After benefits have been paid for predetermined amount of time defined by the Policy, the definition of disability typically changed to include that a person cannot perform the duties of any Gainful Occupation that they are reasonably fitted for by training, education or experience.

This term is defined in each Policy.

Question 59

Any Occupation

Answer 59

A defined term under the OA Long Term Disability Policy, and can be a part of the Total Disability/ Totally Disabled definition. Generally, it occurs after a duration of time as outlined by the Policy where the definition of disability changes from reviewing if a claimant can perform their own occupation, to reviewing if a claimant can perform any occupation. Generally, meaning the ability to perform the duties of any other occupation for which the person is fitted by training, education, experience, age and physical and mental capacity. In most cases, there is a “gainful” component to the definition.

See “Gainful” definition.

Question 60

Survivor Benefit

Answer 60

A benefit offered in OA Disability group coverages that, upon death of the claimant, and under certain conditions a benefit amount may be payable to an eligible survivor.

Question 61

Dependent Child

Answer 61

A child born to the Employee, adopted by Employee, a stepchild living with Employee, whom the Employee has legal guardianship, or whom the Employee must provide insurance in accordance with court order.

Question 62

Social Security Normal Retirement Age

(SSNRA)

Answer 62

The age at which a person is eligible for retirement under the Federal Social Security Act. This is sometimes called Social Security Full Retirement Age (SSFRA).

Question 63

Social Security Application Assistance

Answer 63

AUL determines that a Person is a likely candidate for Social Security Disability Insurance (SSDI), AUL may assist the Person with the application process for these benefits through the use of a Vendor specializing in Social Security benefits. Upon written request, a representative from AUL’s Group Claims Department may supply pertinent information to the Person about:
1. eligibility for SSDI benefits;
2. how to begin the application process;
3. how to submit an appeal;
4. guidelines established by the Social Security Administration for submitting appeals; and
5. names of organizations offering assistance.