Life and Health - Chapter 10

Workers' Compensation Benefits: Income Benefits

(Disability Benefit) -Total Disability - The benefit amount is subject to maximum and minimum weekly limits. -Partial Disability - Benefits restore a percentage of lost wages. -Scheduled Injury - There is a schedule of benefits for specific permanent partial injuries, such as a specific amount for loss of an eye or a specific amount for loss of a hand Benefits do not include extra income and each state sets the eligibility requirements for Workers' Compensation benefits. Because Workers' Compensation is a state-mandated benefit for employees, an individual occupational disability income policy usually includes a coordination of benefits provision that reduces the insurance company's monthly claims liability by the amount of Workers' Compensation income (and/or Social Security Disability Income) benefit paid to the insured. This means individual and group disability benefits will be reduced by the amount of Workers' Compensation benefits. Workers' Compensation is always the primary payor when applicable.

An insured purchases a disability income policy with a 90 day elimination period. If a disability lasts 100 days, the insured would be entitled to receive benefits for: 10 days 90 days 100 days 190 days

10 days The elimination period acts like a time deductible. The insured would be eligible to receive 10 days of benefit payments. Of the 100 days he was disabled, the first 90 are eliminated, leaving the remaining 10 days eligible for claim payment.

All of the following are scenarios in which an insured would automatically qualify for total disability benefits whether or not they could actually continue working EXCEPT: A small business owner contracts a throat disease that causes the inability to speak A dancer slips and falls and sprains an ankle A truck driver is involved in an accident and loses both legs A drummer in a band loses hearing

A dancer slips and falls and sprains an ankle Presumptive disability includes loss of use of any two limbs, total and permanent blindness, and loss of speech or hearing.

Characteristics of a Disability Income Policy: Probationary Period

A probationary period may be included in some disability income policies to protect the insurer from immediate claims. The insurer may have a 15-30 day waiting period before losses due to a pre-existing condition. The probationary period usually does not apply to losses due to an accident.

Permanent Disability

A total disability that reduces or eliminates the insured's ability to work again.

Temporary Disability

An insured is able to continue to work at reduced efficiency or reduced hours, but is expected to fully recover.

The two primary definitions of disability are "any occupation" and "own occupation." Which of these statements best describes the difference between the two definitions? An any occupation policy is more restrictive because it is easier to qualify for benefits An own occupation policy is less restrictive because it is easier to qualify for benefits An own occupation policy is more restrictive because it is harder to qualify for benefits An any occupation policy is less restrictive because it is harder to qualify for benefits

An own occupation policy is less restrictive because it is easier to qualify for benefits An "own occupation" policy is less restrictive because one must only be unable to perform the essential duties of their occupation at the time of disability. An "any occupation" would not pay benefits if the insured could perform the duties of any occupation for which he/she was suited by reason of education, training, or prior experience, and is considered more restrictive.

From the insured's perspective, which of the following types of disability coverage would be the most restrictive as to qualifying for benefit payments? Any occupation Own occupation Social security Workers' compensation

Any occupation Under any occupation, an insured is disabled if he/she cannot perform the duties of any occupation for which he/she is suited by reason of education, training, or prior experience. This is more restrictive than if an insured is unable to perform the essential duties of his/her own occupation.

Return of Premium Rider

At specified policy years (typically after 10 years) the insurer will provide a refund of 80% of premiums paid in to that point less any dollar amounts paid out in claims. This optional rider has a premium requirement which can be an additional 40-60% of the base policy's premium.

Cost Of Living Rider

Automatically increases monthly benefits after the onset of a disability, as the Consumer Price Index (CPI) increases. An adjustment in benefits is made on each anniversary while the disability continues and protects the insured against inflation.

Social Security: Disability Income Benefits

Based on the employee's average indexed monthly earnings on which Social Security taxes have been paid. This is referred to as the Primary Insurance Amount (PIA). Benefits cease when the employee reaches age 65, dies, or is no longer disabled. Beginning at age 65, the insured worker is eligible to receive retirement benefits. Benefits cease when the employee reaches Social Security's definition of Full Retirement Age, dies, or is no longer disabled. When Full Retirement Age is reached, the insured worker is eligible to receive retirement benefits. The employee is eligible for 100% of the PIA. A spouse and other dependents (parents or children) may be eligible for up to 50% of the amount of the disability benefit received by the disabled individual. A spouse caring for the worker's unmarried child who is under age 16 or was disabled before age 22 also receives a benefit equal to 50% of the employee's PIA. Unmarried children under age 18 (or 19 if still in high school) or if disabled prior to age 22 are also eligible for a benefit equal to 50% of the employee's PIA. The total dollar limit is 150-180% of the employee's disability benefits.

Which of the following terms best describes the maximum length of time that disability income benefits will be paid to the disabled insured? Coverage period Benefit period Disability period Elimination period

Benefit period The benefit period determines the amount of time a benefit will be paid. Benefits are limited by the policy's elimination period, duration of benefit, definition of disability, and any age limitations.

Disability Income Insurance

Disability income insurance is sometimes referred to as "the forgotten need." Many workers think they have coverage through Workers' Compensation insurance without realizing it does not provide coverage for disabilities which occur outside of work. Social Security does provide disability benefits, but qualifying for Social Security Disability Income is less likely due to the restrictive requirements needed to qualify. Having a disability that leaves an insured unable to work not only eliminates income, but also increases expenses due to cost of medical care, rehabilitation, and possibly assistance in the home. Because of the extra expense, the financial impact of a disability may be greater than that of premature death. To protect against these losses, an individual may choose to purchase a disability income policy.

Total Disability

Disability policies will pay benefits according to one of two definitions of total disability Own occupation - Some policies require the insured's inability to perform the main duties of his/her own occupation. The own occupation definition often applies for the first 2 years of a disability, then changes to any occupation. This definition is the least restrictive and is easier to qualify for benefits. It is typically reserved for more skilled occupations and may result in a higher premium Any occupation - Some policies are stricter and require the insured to be unable to perform the duties of any occupation for which he/she is reasonably suited by education, training, and experience. This definition is more restrictive and harder to qualify for benefits. In order to qualify for disability benefits, it may be required that the insured be under the care of a physician, regardless of the definition used in the policy.

Partial Disability

Disability resulting in an inability to perform 1 or more of the regular duties of an occupation. The benefit usually pays up to 50% of a total disability benefit for 3 to 6 months.

Non-Disabling Injury Rider

Does not pay disability income, but pays the medical expenses that are related to an injury that does not result in total disability (such as Emergency Room, x-rays, durable medical equipment, etc.). It is a limited form of medical expense coverage added to a disability income policy.

Impairment Rider

Eliminates coverage for preexisting conditions, such as back injuries. Attaching this rider excludes coverage for a condition that would otherwise be covered. The use of this rider may make insurance obtainable for an otherwise uninsurable person.

Lifetime Benefit Rider

Extends the benefits for life if total disability begins before a specified age. If disability begins when the insured is older than the age specified, the rider is not in effect.

Guaranteed Purchase Option (Guaranteed Insurability, Future Increase) Rider

Guarantees that on specified dates, ages, or occurrences, such as marriage, birth of a child, etc., the insured may purchase additional monthly benefits, if income justifies it, without proof of insurability. Rates are based on attained age. Some insurers refer to this as a Future Increase Option (FIO).

Disability Reducing Term

Helps a small business that has long-term commitments requiring monthly or other regular payments meet their obligations. The amount of coverage remains the same monthly, but the benefit period reduces as the debt reduces.

Social Security: Waiting Period (5 "full" months)

In general, benefits start with the 6th full calendar month of disability and are not retroactive to the date of disablement. In no event are benefits retroactive prior to the date of application for disability determination. Accordingly, a person should apply for SSDI benefits as soon as possible following their disabling event. To be considered a "full" month of disability, the individual must be disabled prior to the first day of a month and remain disabled through the last day of a month (a person first disabled after midnight on the first day of a month will not begin a full month of disability until the first day of the following month).

Waiver Of Premium Rider

In the event total disability continues beyond a specified period, future premiums will be waived by the insurer for the duration of the disability.

Unique Aspects of Individual Disability Underwriting

In underwriting disability income, the insured's occupation is the single most important rating factor because a worker in America is more likely to suffer a disability than die prior to age 65. Insurance companies writing disability income generally have an occupational classification system based on considerations, such as job duties, claims history of the occupation, and stability of the industry. The concept of morbidity is also used to determine the frequency of illness and injury that occur within a group of individuals over a stated period of time. This is used to help predict losses that lead to disability claims. The change of occupation provision in a disability income policy could result in a change of benefits depending on the new occupation, or the insurer could change the amount of premium to fit the occupational rating for the current level of benefit. The more hazardous the occupation, the less benefit and/or the higher the premium. Consideration is also given to any hazardous hobbies, such as bull riding, skydiving, and bungee jumping, which would affect the rating or require an exclusion rider. In addition to occupation, other factors influence both underwriting and rates, including age and gender, and a person's prior health history. When a person is approved by underwriting, the final rate is determined by the amount of benefit purchased, the duration of the benefit period, and on the elimination period. Individual plans can provide for greater indemnity amounts, longer benefit periods, and are typically issued with noncancellable or guaranteed renewable provisions. Benefit limitations will also be determined during underwriting. The benefit may be based on a percentage of income or stated as a flat dollar amount based on income at the time of underwriting, not the time of loss. Once all underwriting information has been reviewed, the underwriter must determine if the risk is insurable or not. If uninsurable, the risk will be declined. If insurable, the risk may be standard or substandard. If substandard, the insurer may want to reduce the risk. This may be accomplished by use of one or a combination of the following: -Charge an extra premium or surcharge -Increase the elimination period, shorten the benefit period, reduce the amount of benefit or some combination thereof -Utilize a Full Exclusion Rider when a condition appears certain to result in recurrent disabilities

Unique Aspects of Individual Disability Underwriting: Common Exceptions

Individual disability income policies typically exclude coverage for losses caused by: -Aircraft, except for passengers on a regularly scheduled flight -War or acts of war -Attempted suicide or self-inflicted injuries -Normal pregnancy -Pre-existing conditions -Commission of a felony

Presumptive Disability

Loss is presumed to be total and permanent due to the loss of sight, hearing, speech, or the loss of 2 limbs. Benefits paid under presumptive disability are usually paid in a LUMP SUM. Lump sum payments are based on the assumption the insured will not be able to return to work.

Additional Monthly Benefit (AMB) Rider

Many insurance companies offer a short-term additional benefit in the form of a rider. The rider normally covers the first 6 to 12 months of a disability. Some insurers refer to the rider as a Social Security Rider as it pays benefits while the insured is awaiting Social Security Benefits. The rider is not related to Social Security and, therefore, an AMB Rider is used to define the benefit. The short-term benefit could supplement either a government or private benefit plan. Unlike the SIS, this rider (AMB) does not consider the amount of a Social Security Benefit. It is strictly in addition to all other disability benefits.

All disability policies cover ___________________________ disabilities, which are those occurring outside work. Occupational Contributory Noncontributory Nonoccupational

Nonoccupational All disability policies cover nonoccupational injuries and illnesses. Occupational policies also cover work-related disabilities, which is important for self-employed persons, highly paid employees, and persons with very specialized skills (such as physicians, accountants, engineers, attorneys).

One of the most important underwriting factors in disability income insurance is ________. Number of quarters paid into social security Marital status Occupation Pre-tax (Gross) Income

Occupation A person's occupational classification is one of the primary underwriting factors. When a person works in more than one occupational class, the one which poses the greater risk of disability will determine the classification for underwriting purposes.

A Business Overhead Expense policy, as a form of disability insurance, provides payments for all of the following except _________________________. Employee wages Owner's income Taxes, utilities, rent Raw materials used to manufacture goods sold

Owner's income A Business Overhead Expense policy will not pay the wages of the business owner. By paying the other expenses of the business, the business can remain financially stable until the owner is able to return to work.

Rehabilitation Benefits

Paid while the insured is totally disabled and receiving benefits, if the insured elects to participate in some form of vocational rehabilitation approved by the insurer. Total disability benefits will be continued as long as the insured is actively participating in the training program and remains totally disabled.

Key Employee Insurance

Pays a benefit to the business when a key employee becomes disabled by helping pay for a replacement, train a new employee, or replace loss of revenue due to the disabled employee's lack of ability to work.

Buy-Sell Agreement or Disability Buyout

Pays a lump sum, enabling a partnership or business to buy out the totally disabled principle's interest in the business. A cross-purchase plan requires each partner to purchase a separate disability policy on each of the other partners. An entity plan provides for the business to purchase a disability policy on each partner.

Types of Policies: Disability Income (Indemnity) Policy

Pays an income benefit when the insured is unable to work due to illness or injury (even if injured on vacation). Benefits are paid weekly or monthly and determined as a flat benefit or a percentage of the insured's current earnings, normally 60% - 70%. The full income is not paid in order to reduce malingering. In other words, if the insured received 100% income replacement, he/she would not be very motivated to recover and return to work.

Social Insurance Supplement (SIS) Rider

Pays in addition to regular disability policies until Workers' Compensation or Social Security payments begin. It is also designed to provide benefits if social security is declined. If either benefit stops, the SIS will pay benefits. The SIS, which was developed by private insurers to reduce over insurance by matching Social Security as closely as possible, is normally written for a specified period of time.

An insured owns a disability income policy that has a waiver of premium rider in the event he/she suffers a total disability. 5 years after the issuance of the policy, the insured suffers a disability and is unable to work for 18 months before returning to work. The rider has a 3 month waiting period. Which of the following best describes the benefits of the waiver of premium rider? Since the disability was not permanent, no benefits are received from the rider The first 3 months premium waived Premiums will be waived retroactively to the beginning of the disability All premiums will be waived during the period of disability except for the first 3 months

Premiums will be waived retroactively to the beginning of the disability The insured would have had to have paid the first three months premium until he/she was on claim, then the company would have refunded those premiums and waived the rest of the premiums while he was still on claim.

Residual Disability

Provides benefits for loss of income after the insured returns to work usually following a total disability. Benefits are based on the reduction of earnings as a result of the disability. Both partial and residual disability benefits are referred to as "at-work" benefits since the insured is able to work and continue to receive benefits. All other disability benefits are considered "24 hour" benefits.

Business Overhead Expense

Provides the funds to cover the overhead expenses of a business when the owner becomes disabled. The benefits include expenses such as office rent, utilities, and employee labor. However, the owner cannot collect for loss of income under this policy.

A disability that is presumed to result from the same or a related cause of prior disability is a ________________. Recurrent disability Delayed disability Presumptive disability Residual disability

Recurrent disability A disability that was believed to have been resolved, but which returns within a stated period of time (such as 6 months) is known as a recurrent disability.

An insured took out a disability income policy while working in a low hazardous occupation. When filing a claim for disability income benefits, after a job related accidental injury, the insurance company discovered the insured changed jobs 2 years prior to the loss. The new job would have been classified as more hazardous. The insurance company will most likely: Reduce the benefit payment dollar for dollar to account for the premium underpayment Pay no benefit since the insured failed to inform the insurance company on a timely basis of the change in occupation Reduce the benefit to an amount the actual premium paid would have purchased under the proper job classification Pay the benefit as contracted for since the policy is over two years old

Reduce the benefit to an amount the actual premium paid would have purchased under the proper job classification The insurer will pay only the amount of benefit that the insured would have been able to purchase, with the premium already paid, for the more hazardous job, so his benefit will be reduced accordingly.

Which of the following are ways that the insurer can issue disability income coverage for a substandard risk? Rated up in age, graded benefit, temporary lien Reduced benefit, higher premiums, rider excluding coverage COLA waiver, future purchase waiver, waiver of premium Higher premium, higher benefit, shorter elimination period

Reduced benefit, higher premiums, rider excluding coverage Reduced benefits, higher premiums, and elimination of coverage for known risks (preexisting health conditions, vocational/avocational risks) are three of the ways in which insurers deal with substandard risk.

Social Security Disability Income Limitation

SSDI benefits are secondary to Workers' Compensation and any other public insurance benefits. If the total of SSDI, Workers' Compensation, and other public disability benefits exceeds 80% of the worker's pre-disability earnings, the SSDI benefit will be reduced dollar-for-dollar until the 80% limitation is reached.

The elimination period in a disability income insurance policy: Defines what causes of loss are eliminated from potential claim payment Serves as a time deductible before benefits are payable Addresses where accidents and sicknesses must not occur in order for a claim to be payable Describes how long the policy must be in force before claims can be considered

Serves as a time deductible before benefits are payable The elimination period is the period for which an insured person must be disabled before benefits begin. Benefits begin only after this period of time is satisfied.

Short-Term Disability

Short-Term Disability Income plans are characterized by maximum benefits for periods of rather short duration, such as 13, 26, or 52 weeks. Often, benefit periods are coordinated with the employer's "sick pay plan." Short term disability plans will not pay benefits for disabilities lasting longer than 2 years. The elimination period may be as short as zero days for accident and 7 days for sickness but is rarely more than 15 or 30 days. Benefits are typically paid weekly and range from 50% to 100% of the individual's income.

Annual Renewable Term

Some companies will allow an insured to add a life insurance rider to a disability income policy in the form of annual renewable term. This provides additional death benefits if the insured dies due to a disability.

Any occupation

Some policies are stricter and require the insured to be unable to perform the duties of any occupation for which he/she is reasonably suited by education, training, and experience. This definition is more restrictive and harder to qualify for benefits. In order to qualify for disability benefits, it may be required that the insured be under the care of a physician, regardless of the definition used in the policy.

Own occupation

Some policies require the insured's inability to perform the main duties of his/her own occupation. The own occupation definition often applies for the first 2 years of a disability, then changes to any occupation. This definition is the least restrictive and is easier to qualify for benefits. It is typically reserved for more skilled occupations and may result in a higher premium

Characteristics of a Disability Income Policy: Elimination Period (Waiting Period)

The elimination period (sometimes referred to as a "time deductible") is the time period an individual must be disabled before benefits become payable. This waiting period for a disability due to an illness is usually longer than for an injury due to an accident. For example, a policy may have a 6-month elimination period for loss due to a sickness and waive the elimination period to provide immediate coverage in case of an accident. The elimination period can be selected by the policyowner at the time the policy is purchased. The length of the elimination period will directly affect the premium. A shorter waiting period will result in a higher premium

Occupational

The policy covers a disability due to injury and sickness which occurs either on or off the job.

Nonoccupational

The policy covers a disability due to injury and sickness which occurs off the job only.

Social Security Disability Insurance - Part of OASDI

The qualification for Social Security disability benefits is contingent upon the employee having the proper insured status, either "fully" insured (40 credits), disability insured (20 of which were earned in the last 10 years), or "currently" insured (a sliding scale based on age, beginning with 6 credits in the past 13 quarters for persons age 21 to 24), and satisfying the waiting period.

Characteristics of a Disability Income Policy: Benefit period

The time period the insured is eligible to receive payments after the elimination period has been met. The benefit period may be written for a specified number of year (2, 5, or 10 years), to age 65 or for life. The policyowner can purchase a policy with a short or long benefit period. A longer benefit period will result in a higher premium.

Qualifying for Disability Benefits

There are two types of disability policies (other than Workers' Compensation insurance) that can be purchased as an individual plan or part of a group plan: Occupational - The policy covers a disability due to injury and sickness which occurs either on or off the job. Nonoccupational - The policy covers a disability due to injury and sickness which occurs off the job only.

Long-Term Disability

This coverage is often characterized by benefit periods of 2 years, 5 years, to age 65, or lifetime. The elimination period will most commonly be either 30, 60, 90 or 180 days. It may be possible to obtain a LTD policy with a two-year elimination period, to be used in conjunction with a short term disability policy that pays benefits for 2 years. Benefit amounts are usually limited to typically 2/3 of the participant's income. Benefits stated in a policy are the maximum benefit amounts and maximum period of time covered. Normally, the waiver of premium for disability applies after a period specified in the policy.

Cash Value (Surrender) Rider

This form of a return of premium begins building values equal to a percentage of premiums paid for a disability policy. The values start building around the third year and build to 100 percent at age 65, which can be returned to the insured at that time, less any claims.

Social Security: Definition of Disability

To collect Social Security disability benefits, an employee must be unable to engage in any substantial gainful activity due to a medically determined physical or mental condition that has lasted or is expected to last at least 12 months or result in an early death.

In addition to language similar to the any occupation definition of total disability, Social Security's definition of disability also includes which of the following statements? Unable to perform any substantial gainful activity Unable to perform more than 50% of one's customary duties Unable to sit, stand, or lie down for extended periods of time Unable to qualify for benefits under any personal or state-sponsored disability insurance plan

Unable to perform any substantial gainful activity Social Security's definition of disability includes the statement about unable to perform any substantial gainful activity, which makes qualifying for SSDI benefits difficult in many cases.

Types of Policies: Pure Loss of Income (Income Replacement) Policy

Under this policy, the insured will receive benefits if loss of income is due to a covered accident or sickness, even if the insured is able to work full-time doing all the same duties as before the loss occurred. With traditional disability income policies, there has to be a loss of time or duties to trigger coverage, but under the Pure Loss of Income policy the insured is eligible based solely on a loss of income. The insurer will consider any other sources of disability income the insured may be entitled to when underwriting the policy. The purpose is to prevent over insurance that could cause a moral hazard or fraudulent claim. Disability benefits are typically paid monthly, but can be paid on a weekly basis. The amount of the benefit payable is found in the policy and is based on income reported at the time of application.

Workers' Compensation Benefits: Medical Benefits

Unlimited as to time, but dollar amounts payable may be limited by law.

Hospital Confinement Rider

Waives the elimination period if insured is hospitalized during the period of elimination, but only pays when being treated as an inpatient.

Recurrent Disability

When a second disability is suffered due to the same cause within a certain period of time (usually 6 months), the elimination period will not apply and the disability will be considered continuous.

Transplant Donor Benefit

When an insured is totally disabled because of the transplant of an organ to another individual, the insurer will deem the insured to be disabled as a result of sickness.

Coordination of Benefits

When it comes to receiving disability income benefits, both Workers' Compensation and Social Security Disability Income benefits have an effect on other benefits to which a person may be entitled. Because Workers' Compensation benefits are mandated by state (or federal) law, they are primary to any other insurance benefits.

Group Disability Income: Underwriting Group Disability Plans

When writing disability income insurance on a group basis, there is no medical underwriting. The field underwriter's job is to guard against adverse selection and overinsurance. Group disability income insurance is usually offered only on a nonoccupational basis, which will not cover work-related disabilities. Work-related injuries are usually covered under Workers' Compensation Insurance. Most insurers require that a minimum number of employees participate in a group plan. This enables the insurer to issue the plan without evidence of insurability.

Workers' Compensation

Workers' Compensation benefits are primary to either individual or group disability income benefits. The individual or group benefit will be reduced dollar-for-dollar by the amount of Workers' Compensation benefits paid, so that the total disability income benefit payable from all sources combined will not exceed the amount that would be payable by the individual or group disability policy on its own.

State Workers' Compensation Benefits

Workers' Compensation coverage applies to bodily injury and or occupational diseases that arise from and in the course of employment. There are 4 "statutory claims" for benefits under most states' Workers' Compensation laws: Disability Income, Rehabilitation (job retraining), Medical Expenses, and Survivors' Income (including a burial benefit).

The Age Discrimination in Employment Act (ADEA)

affects both the short- and long-term group disability benefits for the people employed after age 65. This, in turn, will have some effect on premium determination by the insurer when underwriting a particular group.