Many of the definitions in the SPD are such a catch 22, as the wording contradicts prior defining statements and continuous following other statements make it impossible according to these terms, to have an OWN OCCUPATION
Define gainful occupation according to your policy terminology:

(Gainful occupation):
Means any occupation in which the insured employee is or could reasonably become qualified considering his or her education, training, experience, mental and physical abilities, could reasonably find employment, considering the demand in the national labor force and could or reasonably expect to earn a before tax income at least equal to 60% of his or her predisability income within 12 months of returning to work.

(Main duties or material or substantial duties):


means those job tasks that are normally required to perform the insured employees own occupation and could not reasonably be modified or omitted. To determine whether a job task could reasonably be modified or omitted the company will apply the american with disabilities act( ADA) standards concerning reasonable accommodation. It will apply the acts standards, whether or not, the employer is subject to the act or the insured employee has requested such a job accommodation, an employers failure to modify or omit other job tasks does NOT render the insured employee unable to perform the main duties of the job.
Main duties include those job tasks as described in the U.S department of Labor dictionary of occupational titles and as performed in the general labor market and national economy. Main duties are NOT limited to those specific job tasks as performed for a certain firm or at a certain work site.


(Own occupation or regular occupation)


means the occupation, trade or profession in which the insured employee was employed with the employer prior to disability and which was his or her main source of income prior to disability. It means a collective description of RELATED jobs as defined by the U.S department of labor dictionary of occupational titles. It includes ANY work in the same occupation for pay or profit, regardless of whether such work is with The employer, with some other firm or self employed or whether a suitable opening is currently available with the employer or in the local labor market.


Totally disabled or total disability:

will be defined as follows, during the elimination period and own occupation period it means that due to sickness or injury the insured employee is unable to perform each of the main duties of any gainful occupation. The loss of a professional license, occupational license, or certification, or a drivers license for any reason does NOT by itself constitute total disability.

FYI there are OTHER definitions as well...however, not too bad of an explanation with some tweaking it would be somewhat better, but nevertheless, its OK as is!

Another confusing aspect from these disability polices ( ie) some of the information copied in prior post from one found) in that same policy it goes on to describe partial disability and all the terms and conditions, however from that policies definition of gainful occupation it states AFTER the own occupation period that ANY gainful occupation where you don't earn 60% of your predisability income before tax, then would one assume they would be considered totally disabled ( according to their OWN definition of totally disabled and gainful occupation?

Its the terms of their own policy and their own definitions of same and so according to their definitions one would be considered totally disabled if they could not perform all of the main duties of ANY occupation as well earn 60% of their predisability income before taxes, so under this scenario if one could not perform each or all of any gainful occupation and could earn 60% of predisability wages then the benefit would still be awarded to the claimant, irrespective of the 24, 36, 60 month own occupation period ( which ever the case)

So if I understand this correctly if one earned 2000 weekly before tax in their won occupation and due to residual disability could not perform each and all job duties from any occupation and couldn't earn 1200 a week ( thats 60% of the predisability income ) They would still get benefits irrespective of the 24,26,60 month own occupation period.


Right, so where would a partial disability fall into this?

<< FYI there are OTHER definitions as well...however, not too bad of an explanation with some tweaking it would be somewhat better, but nevertheless, its OK as is! >>



Awwww Larry you responded before my latest post this was merely a copy of another policy definition, copied AS IS ( I didn't write this LOL)

XXX

nursingangel...collectively, we who are responding, are pleased to have learned, that you are enjoying the responses and why don't you join us and contribute your knowledge,further, we enjoy your predictable snide remarks which never seems to get exhausted, regardless of the subject matter...is there no end to your boundless talent??

Oh my, is there anything wrong with being respectable, apologetic, agreeing to disagree at times and still remain civil? ANY-HOO. I am sincerely interested in deciphering disability policies definitions and meanings as they pertain to all who are disabled. I gave an example of a policy and the definitions and seriously am interested in what professionals or those in the know, KNOW...LOL

As per no one responding, fact is I don't see any responses to anything here. ( so its not as if we ran anyone off, they are just.... MIA) I think perhaps some who may be able to respond are out Christmas shopping still

XXX

Partial or Residual would come into the accounting if the carrier did not think the claimant was disabled from ANY occupation and the claimant then decided to get a job they would be paid a partial instead of a Total Benefit based on the formula in the policy.

The Total Disability definition if met allows the claimant not to work but if the definition is not met then the benefit is not paid under the Total Disability claim. If the claimant that is NOT meeting the Total Disability definition DOES NOT work then there is no benefit. If/when they do go back to work then benefits would be paid under the partial/residual definition.

<< Partial or Residual would come into the accounting if the carrier did not think the claimant was disabled from ANY occupation and the claimant then decided to get a job they would be paid a partial instead of a Total Benefit based on the formula in the policy.
The Total Disability definition if met allows the claimant not to work but if the definition is not met then the benefit is not paid under the Total Disability claim. If the claimant that is NOT meeting the Total Disability definition DOES NOT work then there is no benefit. If/when they do go back to work then benefits would be paid under the partial/residual definition. >>


"Thanks for that clarification, BUT, here is the thing, where the definition of GAINFUL OCCUPATION is concerned note it says" :


any occupation in which the insured employee "is" or could reasonably become qualified considering his or her education, training, experience, mental and physical abilities, could reasonably find employment, considering the demand in the national labor force and could or reasonably expect to earn a before tax income at least equal to 60% of his or her predisability income within 12 months of returning to work.

so from that stance AFTER the 24,36,60 month OWN occupation period one is then to be considered for possible work status ( according to their residual DIABILTY " note the definition says ABILITY?, however according to this definition, IF ONE were not able to find a job within their abilities making 60% of their predisability income before taxes, it appears the insured would considered TOTALLY disabled and in accordance as well with this policies definition of totally disabled.

The partial disability would seem to only come into play IF the insured sought work and all they could get was a job making 20% of their predisabilty earnings, in the example used ( 2000.00) that would be roughly 1200.00 a week. However being that the SPD's do not give any guidance what so ever, and only definitions of their terms, in my opinion that is arbitrary and capricious in of itself according to the arbitrary and capricious definition.




My brain had a infarct, I edited this to fix the correct weekly salary.