Chapter 16 Disability Income Insurance and Disability Benefits Programs
Jane fell in the backyard of her home and fractured her left ankle.She had a nonunion fracture and could not work for 28 weeks.For how long will she collect temporary state disability benefits?
26 weeks
temporary disability insurance claims must be filed within how many days in your state?
7 days
regional office
A Social Security state office.
guaranteed renewable
A clause in an insurance policy that means the insurance company must renew the policy as long as premium payments are made. However, the premium may be increased when it is renewed. These policies may have age limits of 60, 65, or 70 years or may be renewable for life.
residual disability
A disability from an illness or injury that prevents an insured person from performing one or more of the functions of his or her regular job. This is sometimes referred to as partial disability.
waiver of premium
A disability insurance policy provision that an employee does not have to pay any premiums while disabled.
cost-of-living adjustment
A disability insurance provision to increase monthly benefits.
Armed Services disability
A disability occurring or aggravated while the patient is in military service.
double indemnity
A feature in some life and disability insurance policies that provides for twice the face amount of the policy to be paid if death results to the insured from accidental causes.
Social Security Disability Insurance program
A federal entitlement program for long-term disability under Title II of the Social Security Act. It provides monthly benefits to workers and those self-employed who meet certain conditions.
disability income insurance
A form of health insurance that provides periodic payments to replace income when the insured is unable to work as a result of illness, injury, or disease-not as a result of a work-related accident or condition
voluntary disability insurance
A majority of employees of an employer voluntarily consent to be covered by an insured or self-insured disability insurance plan instead of a state plan.
consultative examiner
A physician who is paid a fee to examine or test a person for disability under either the SSDI or SSI program.
Federal Employees Retirement System
A program for federal employees hired after 1984 or those hired before 1984 who switched from CSRS to FERS.
Civil Service Retirement System
A program for federal employees hired before 1984.
Veterans Affairs disability program
A program for honorably discharged veterans who file claim for a service-connected disability.
short-term disability insurance
A provision to pay benefits to a covered disabled person as long as he or she remains disabled, up to a specified period not exceeding 2 years.
long-term disability insurance .
A provision to pay benefits to a covered disabled person to age 65
Disability Determination Services
A state Social Security division office that assesses a case for disability benefits.
total disability
A term that varies in meaning from one disability insurance policy to another. For example, a liberal definition might read, "The insured must be unable to perform the major duties of is or her specific occupation."
residual benefits
A term used in disability income insurance for disability that is not work related. It is the payment of partial benefits when the insured is not totally disabled.
AIDS
Acquired Immune Deficiency Syndrome
Social Security Administration
Administers SSDI and SSI programs for disabled persons.
Veterans Affairs outpatient clinic card
An identification card belonging to a retired member of the armed forces that is shown when receiving medical or dental services for service-related disabilities from a clinic.
accidental death and dismemberment
An insurance policy provision that protects the insured if he or she suffers loss of sight or loss of limb(s) or death by accident.
Name 4 states that allow for maternity benefits in normal pregnancy.
CA Hawaii New Jersey Rhode Island
How long can a person continue to draw state disability insurance benefits
CA 52 weeks Hawaii,New Jersey,New York,Puerto Rico 26 weeks Rhode Island 30 weeks
Name the states and the territory that have nonindustrial state disability programs.
California- California unemployment insurance code Hawaii-Temporary Disability Insurance Law New Jersey-Temporary Disability Benefits Law New York-Disability Benefits Law Puerto Rico-Disability Benefits Act Rhode Island-Temporary Disability Insurance Act
CSRS
Civil Service Retirement System
CE
Consultative Examiner
DDS
Disability Determination Services
Health insurance that provides monthly or weekly income when an individual is unable to work because of a non industrial illness or injury is called:
Disability income insurance
supplemental benefits
Disability insurance provisions that allow benefits to the insured to increase the monthly indemnity or receive a percentage of the policy premiums if an individual keeps a policy in force for 5 to 10 years or does not file any claims.
if a woman has an abnormal condition that arises from her pregnancy and is unable to work because of the condition, she may not receive state disability benefits
False
when a person insured under a disability policy cannot, for a limited period of time, perform all functions of her/her work, this is known as permanent disability.
False
FERS
Federal Employees Retirement System
HIV
Human Immunodeficiency Virus
Unemployment Compensation Disability
Insurance that covers off-the-job injury or sickness and is paid for by deductions from a person's paycheck. This program is administered by a state agency.
Vincent Michael Was ill with bad cold for 1 week. Will he get temporary SDI?
No - because he was only out for the duration of the waiting period
Betty Kraft had to stay home from job due to daughter with measles. She applied for temporary state disability benefits. Will she get paid?
No - she has to be the one ill
John S. Thatcher stubs toe as he is leaving work and going to his car parked on the street.Because the injury was only slightly uncomfortable,he thought nothing about it.The next morning he found that his foot was too swollen to fit in his shoe,so he stayed home.When the swelling did not subside after 3 days,John went to the doctor.Radiographs showed a broken toe,which kept John home for 2 weeks.After a week he applied for temporary state disability benefits.will he be paid?Why or why not?
No because he injured himself on work property which means it is a liability case from his place of employment
Frank Thompson is a box boy at a supermarket on saturday and sundays while a full time student at college.He broke his leg while skiing and cannot work at the market,but he is able to attend classes with his leg in a cast.Can he collect state disability benefits for his part time job?Why or why not?
No because he is only part time and he goes to college
Gene RTW for 3 weeks then develops cold and cough and dx'd again with pneumonia. Can he collect temp SDI?
No because he is past the 15 day period
Betsy Palm works in Hawaii and had an emergency appendectomy & hospitalized for 3 days. Will she get SDI?
No because she has a waiting period of 7 days
Month after retiring EE has GB surgery. Can EE get temp SDI? why or why not?
No once retired no longer eligible
OASDHI
Old Age, Survivors, Disability, and Health Insurance
benefit period
Period of time for which payments for Medicare inpatient hospital benefits are available.
RO
Regional Office
Two federal programs for individuals younger than 65 years of age who have a severe disability are:
SSDI: Social Security Disability Insurance-program SSI: Supplemental Security Income
future purchase option
Same definition as cost-of-living adjustment
temporary disability insurance
See Unemployment Compensation Disability
State Disability Insurance
See Unemployment Compensation Disability.
SSA
Social Security Administration
SSDI
Social Security Disability Insurance program
SSI
Social Security Income
SDI
State Disability Insurance
TDI
Temporary Disability Insurance
reconsideration
The first level of appeal process for an individual applying for SSDI or SI. It is a complete review of the claim by a medical or psychological consultant or disability examiner team who did not take part in the original disability determination.
temporary disability
The recovery period after a work-related injury during which the employee is unable to work and the condition has not stabilized; a schedule of benefits payable for the temporary disability.
hearing
The second level of the appeal process for an individual applying for Social Security Disability Insurance or Supplemental Security Income. This is a hearing before an administrative law judge who had no part in the initial or reconsideration disability determination.
True or false: when a claim form is submitted for a patient applying for state disability benefits, the most important item required on the form is the claimant's social security number
True
hospital benefits may be paid for nonoccupational illness or injury under Hawaii and Puerto Rico's temporary disability benefits prepaid health care programs
True
to be eligible to apply for disability benefits under Social Security, an individual must be unable to perform any type of work for a period of not less than 12 months
True
UCD
Unemployment Compensation Disability
VA
Veterans Affairs
Nick Tyson recovered since a previous illness ended and become ill again with the same ailment - is he entitled to SDI?
Yes
Peggy Jonson has an ectopic pregnancy and is unable to work because of complications of this condition.Can she receive state temporary disability benefits?
Yes - complications of pregnancy covered
Erza Jackson has disability income insurance in a group policy; Erza makes no contribution to policy premiums One evening he goes inline skating and suffers a complex fracture of the patella,which necessitates several months off work. Are his monthly disability taxable? Why or why not?
Yes because the EE is not making any contributions towards the premiums
While walking the picket line with other employees on strike.Gene Berry came down with pneumonia.The doctor told him to stay home from work.Would he be able to collect temporary state disability benefits?Why or why not?
Yes may have become ill while working whether on strike or not
Jerry Slate is out of a job and is receiving unemployment insurance benefits.He is now suffering from severe intestinal flu.The employment office calls him to a job interview for a job,but he is too ill to go.Can he collect temporary state disability benefits for this illness when he might be given a job?Why or why not?
Yes one must either be employed full or part-time OR actively looking for work
partial disability
a disability from an illness or injury that prevents an insured person from performing one or more of the functions of his or her regular job.
Supplemental Security income
a program for income support for low income, aged, blind, and disabled persons
After a claim begins, when do basic state disability benefits become payable if the patient is confined to his or her home? if the patient is hospitalized?
after the 7th day of disability HI and Puerto Rico - after the 1st day; other states after the 7th day
noncancelable clause
an insurance policy clause that means the insurance company cannot increase premium rates and must renew the policy until the insured reaches the age stated in the contract.
Name the two methods or options for billing on a Veterans Affairs patient seen on an emergency basis.
bill the VA monthly patient pays physician and then gets reimbursed by the VA
A SSA division that determines an individual's eligibility to be placed under the federal disability program is called
disability determination services
Some insurance contracts that pay twice the face amount of the policy if accidental death occurs may have a provision titled:
double indemnity
If an insurance adjuster notices some conflicting data on a disability income claim forms, what other documents may be requested to justify payment of benefits?
employer records wage statements tax forms medical records
Provisions that limit the scope of insurance coverage are known as what?
exclusions
waiting period
for disability insurance, the initial period of time when a disabled individual is not eligible to receive benefits even though unable to work
Another disability income insurance term for benefits is called what?
indemnity
Permanently disabled person applies for federal disability benefits. To establish eligibility for benefits under this program, data allowed must be how old?
no more than 1 year old
When the purchase of insurance is investigated, the wor/words to look for in the insurance contract that mean the premium cannot be increased at renewal time is/are
noncancelable clause
exclusions
provisions written into the insurance contract denying coverage or limiting the scope of coverage, for certain conditions or services
When an individual who is insured under a disability income insurance policy cannot perform one or more of his/her regular job duties, this is known as what type of disability?
residual or partial
The SSA may hire a physician to evaluate an applicant's disability. A physician's role may be any one of the following
treating source - provides evidence on behalf of pt consultative examiner - paid a fee & examines, tests pt. full or part-time medical or psychological consultant reviewing claims for a state regional office
The time period from the beginning of disability to receiving the first payment of benefits is called what?
waiting period
When an individual becomes permanently disabled and cannot pay the insurance premium, a desirable provision in an insurance contract is what?
waiver of premium
Jamie Woods a Navy petty officer suffers an accident aboard the USS Denebola 3 weeks following his honorable discharge. To receive veteran's benefits for this injury, the time limit in which ta claim must be filed is what?
within 1 year from the date of the injury