Aside from the complexities accompanying a long-term disability claim application or appeal, insurance companies often use an overwhelming amount of technical terms, which can increase confusion and frustration in an already elaborate process.
While exact wording may vary, this guide provides important definitions of commonly used long-term disability keywords and phrases to help you understand the claim process better. Part 1 of this glossary will include terms starting with the letter A through N, with Part 2 covering terms beginning with the letter O through Z.
Long-Term Disability Phrases and Keywords
Also referred to as a Case Manager, this insurance company representative will correspond with you throughout a claim. The adjuster is responsible for reviewing your submitted medical documentation and will determine whether you are eligible for disability benefits.
Related to the Change of Definition Date. The test of disability often occurs after 24 months of a long-term disability claim. To meet the “any occupation” test, an insured must prove that they cannot work in any occupation suited for by education and/or training.
Attending Physician Statement
A standard form includes information about an applicant’s diagnosis, treatment plan, clinic findings, restrictions and limitations, and return to work plan, among other things. A doctor must complete this form as a part of the long-term disability application.
The amount which the insurance company is required to pay an insured. Generally, benefits are paid monthly. The benefit amount entitlement is typically set out in the Policy or Schedule of Benefits.
Change of Definition Date
The date on which the test for total disability changes from the “own occupation” test to the “any occupation” test. This change usually occurs after an insured has received long-term disability benefits for 24 months. To continue to receive benefits, an insured must prove that they meet the new test for disability.
Cost of Living Adjustment (COLA)
An adjustment is made to the benefit amount that corrects inflation. This provision may be dependent on the insured’s insurance plan. If an insured’s Policy does not contain this provision, the benefit amount will likely remain the same throughout their long-term disability claim.
The date on which the insurer terminated disability benefits.
Date of Disability
The date on which an insured could no longer work due to disability.
Elimination or Qualifying Period
A period during which an insured must wait between the date of disability and the date at which they are eligible to receive their monthly benefit amount. The insured may be required to prove that they have remained disabled throughout the elimination or qualifying period in order to be approved for long-term disability benefits. Waiting periods are usually defined in an insured’s Policy and often last 30, 60, 90, or 120 days.
A Policy provision which eliminates coverage for certain types of disabilities, conduct or conditions. The Policy will often detail what is not covered, including pre-existing conditions. If a claim is denied based on an exclusion, it is important to consult a disability lawyer to determine whether the insurance company was correct in their denial.
Functional Capacity Evaluation
A medical evaluation in a clinical setting assesses the extent of an insured’s functional abilities and capacity to work. Evaluations may be completed by an occupational therapist, physiotherapist, or kinesiologist. An insurance company may require an insured to attend an evaluation to determine their eligibility for benefits. However, suppose an insurer denies or terminates an insured’s benefits based on the evaluation results. In that case, a consultation with a disability lawyer may help determine whether the denial or termination was made appropriately.
A policy often defines employment that suits an insured’s skills, training and education. Some Policy definitions may also include a percentage of income which will equate to an insured being capable of gainful employment. Gainful Employment is often assessed as the Change of Definition Date approaches.
Insurance coverage is offered to a group of individuals, typically offered by employers as a work benefit to their employees. A person covered under a group policy may be referred to as a plan member.
Independent Medical Examination
A medical examination that an insured must attend is arranged by and paid for by an insurance company or disability plan administrator. Suppose an insurer denies or terminates disability benefits based on the examination results. In that case, it is important to consult with a disability lawyer to ensure that the denial or termination was made on the proper basis.
An insurance policy which an individual has purchased themself.
An individual who is covered under an insurance policy.
Internal Appeals Process
Internal Appeals differ from a court proceeding as they are assessed and determined by the insurance company. However, because this is the same organization that initially denied or terminated an insured’s benefits, results may not change.
Cuming & Gillespie LLP Disability Lawyers in Calgary Guide Clients Through the Long-Term Disability Appeals
The experienced disability lawyers at Cuming & Gillespie LLP are familiar with the nuances of long-term disability claims and appeals. Our lawyers understand the frustration and financial concerns that can arise when a benefits claim is denied or terminated. Our team thoroughly reviews policies and gathers evidence to prepare the best possible appeal for each client. Located in Calgary, our firm happily represents clients throughout Calgary, Edmonton, and throughout Alberta. To speak with a member of our long-term disability team, call us at 403-571-0555 or contact us online.