DB Claims 4 - Disability-specific Flashcards
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Accident
An unforeseen and unintended event.
Accidental Bodily Injury
Injury to the body of the insured occurring as a result of an accident.
Timely
Means an employee requested coverage within the eligibility period or grace days.
Date of Disability
The date a person becomes disabled and the elimination period begins.
Elimination Period
The time period a person must wait from the date of a covered injury or illness while off work before benefits are payable.
Accumulated Sick Leave
The number of sick leave days accrued by an employee at a given point in time. Usually used in conjunction with the elimination period of the policy.
Actively at Work
Defines the requirement that an employee must be at work on their effective date of coverage. We consider an employee actively at work if they are out due to: • Regularly schedule day off • Holiday • Vacation Day • Jury Duty • Funeral Leave • Personal time off If the employee is off for any of the above and physically able to work, they will be considered actively at work. The employee must have worked the day immediately prior to their absence to be considered actively at work.
Partial Disability
A partial disability benefit protects the insurer against malingering and lack of employee motivation to return to work. The benefit is valuable for employees as well because it allows them to return to work while performing some of the duties of their own occupation or performing all of the duties only part of the time. It provides employees with at least some benefits in addition to what they receive from their employers from their partial work. The benefit also assists employers with managing costly employee absenteeism, controlling healthcare costs, and retaining good, qualified employees.
Total Disability
Requires a 100% loss of income and that the employee is not working due to their condition during and after the Own Occupation period. If a contract includes a total definition of disability, a person would not be considered disabled if he/she is working on a part-time basis. An employer may further restrict the definition of disability by requiring that the person be disabled from performing any Gainful occupation.
Any Occupation
Defined as being able to perform the duties or any other occupation for which person is fitted by training, education, experience, age and physical and mental capacity.
Own Occupation
Defined as being able to perform all the material duties of one’s own occupation on a full-time basis for selected number of years.
Waiver of Premium (WOP)
When an employee is disabled or on medical leave, they can have their premium waived while they are not actively working as long as they fulfill certain criteria.
Continuity of Coverage
Used in take-over cases when an employee is disabled but not eligible for Waiver of Premium but covers employees who are not eligible for insurance because the employee is not actively at work.
Benefit Amount
This is the amount an insured would receive if they were approved for a claim.
Benefit Maximum
The maximum amount allowed in the plan design for any insured.
