Glossary

Own Occupation

Generally speaking, “own occupation” (“own occ”) provisions state that an insured will be considered disabled if he or she is no longer able to perform the duties of his or her occupation.  

In some instances, the insured’s occupation is expressly defined as a particular job or specialty—for example, a group policy intended for dentists might define occupation as meaning “dentist” or something even more specific, such as “oral surgeon.”  In most cases, occupation is defined as the occupation the insured was engaging in at the time of disability—not the occupation the insured was engaged in when he or she purchased the policy. This is significant, because it means that you can alter your occupation if you stop performing certain duties, take on another occupation, or change jobs prior to filing your disability claim.  

Many people also think that there is only one kind of “own occupation” policy.  In actuality, insurers have created several different variations of the “own occupation” provisions, so you must be sure to read your policy’s particular language carefully, even if your agent tells you that you are receiving an “own occupation” policy.

Click here for more information about the different kinds of “own occupation” provisions and how they can affect your ability to collect disability benefits.

Partial Disability

See Residual Disability.

Participation Limit

This is the maximum amount of total coverage an insurer will be willing to provide, after factoring in the coverage that you are already receiving from other insurance companies.

Click here for more information about participation limits.

Peer-to-Peer Calls

The peer-to-peer call is a tactic used by insurance companies to deny or terminate claims.  When you file your disability claim, the insurance company will typically assign your claim to a doctor who they pay to review your medical records and look for ways that they can deny your claim. Next, after you have submitted your medical records, the insurance company will say that it needs more information and tell you that its doctor will be calling your treatment providers over the phone to ask your doctor a few follow-up questions.  The tone of these calls is usually collegial, to put your doctor at ease, and begins with a few straightforward questions.  Once the insurance company’s doctor has developed a rapport with your doctor, he or she will then start to ask questions that are crafted to elicit responses that the company can use to deny or terminate your claim.  For instance, the insurance company’s doctor might ask whether there are alternative treatment options, when your doctor thinks that you will be able to go back to work, etc.  

After the call, the insurance company’s doctor generally sends your doctor a written summary of their discussion.  These summaries often contain statements that are inaccurate and prejudicial to your claim, but your doctor may be too busy to notice and may simply sign off on it without much thought, inadvertently hurting your claim.  The best way to prevent this from happening is to have all correspondence with your medical providers be in writing and go through an attorney.

Click here for more information about peer-to-peer calls and other tactics insurance companies use to deny and terminate claims.

Personal Disability Quotient (PDQ)

PDQ stands for “personal disability quotient.” Your PDQ estimates the likelihood that you will become disabled during your lifetime, based on a number of lifestyle and health factors.

Click here for more information about how to calculate your PDQ.

Physician Care Requirement

See Care Provision.

Pre-Existing Condition Limitations

Generally speaking, pre-existing condition is a physical or mental condition that existed before the effective date of the insurance coverage. Most policies exclude or reduce benefits for pre-existing conditions.

Presenteeism

“Presenteeism” is a term used to describe the phenomenon of showing up to work in spite of illness, impairment, or disability that limits their productivity.  Presenteeism is very common among physicians and dentists.  Oftentimes, physicians and dentists will continue to practice in spite of physical limitations and/or alter their practices to accommodate their limitations, instead of filing for disability benefits.  Sometimes, physicians and dentists will also start working in another capacity, such as an administrative position, or as a real estate agent, etc., to supplement their income. Continuing to work in spite of a disabling condition not only risks the safety of their patients and exposes them to malpractice liability, but also can make it more difficult to file for disability in the future, because they have demonstrated an ability to work in spite of their disability and, in many cases, modified the nature and scope of their occupation under the terms of their policy by reducing their duties or taking on new responsibilities.

Click here for more information about how presenteeism can negatively affect your disability claim.

Private Investigator

Insurance companies often hire private investigators to investigate claimants, with the goal of gathering information that can be used to undercut a disability claim. Private investigators often employ multiple methods of surveillance, including following a paper trail, following and recording a claimant, pre-texting, and monitoring social media/web activity.

Click here for more information about surveillance methods used by private investigators during the claim process.

Punitive Damages

Punitive damages are a potential legal remedy in a bad faith lawsuit against an insurer.  They are intended to deter the insurer from engaging in bad faith practices in the future, and can be substantial.

Recurrent Disability

Most policies provide that if you return to work, but become disabled again within a certain period of time from the same or a related cause, the insurance company will consider you to be still disabled from the original disability and you will not need to satisfy a new elimination period.

Reservation of Rights

When an insurer pays a claim under a “reservation of rights,” it is essentially providing a provisional payment.  Though the insurance company may be sending you a check, it is not admitting that it actually has any liability under the policy.  Instead, it is “reserving the right” to stop paying your claim if it can find evidence to deny it later.  Once the company denies your claim, they can also demand you to repay them whatever proceeds they have distributed to you.

Click here for more information about strategies that insurance companies use to deny or terminate benefits.

Reserves

Disability insurers are required by state regulators to keep a certain amount of money set aside, or “reserved,” to pay future claims.  Any money required to be kept in a reserve is money that the insurer cannot spend on other things or pay out in dividends.  The amount required to be kept in the reserve is determined by the state, depending on factors like how much the monthly benefit is and how long the claim is expected to last.  If the insurance company is convinced that you are totally and permanently disabled, it may seek to offer you a lump sum buyout so that it can release the money in its reserve to use for other purposes, such as providing dividends to its investor.

Click here for more information about insurance reserves and lump sum buyouts.

Residual Disability

A residual disability rider provides a reduced basic monthly benefit in the event that the insured does not meet the definition of “total disability” under the policy, but nevertheless suffers from a disability that affects his or her ability to work and/or capacity to earn income.  Residual disability benefits are typically provided in cases where the insured returns to work on a part-time or full-time basis, but suffers a loss of earnings.  The insurance company calculates what it believes to be the insured’s loss of income, and then pays benefits on a pro rata basis, based upon its calculations.

Click here for more information about how benefits are calculated under residual disability provisions.

Rider

A rider is an amendment that is added to a disability policy in order to expand or limit the policy’s conditions, coverage and/or benefits.

Click here for more information about different types of disability policy riders.

Self-Reported Symptoms

Many policies have a provision that limits coverage for disability benefits due to an illness or injury that is based on self-reported symptoms (sometimes referred to as “subjective” symptoms). These are disabilities that cannot be verified by medical testing. Common examples include headaches, pain, fatigue, stiffness, soreness, ringing in the ears, dizziness and numbness.   Typically, benefits are limited to a period of 24 months.

Click here for more information about the challenges of disability claims involving self-reported symptoms.

Sickness

Many policies distinguish between a disability caused by injury versus one caused by sickness/illness. Disability due to sickness is typically defined as sickness or disease that firsts manifests itself on or after the effective date of a policy, while it is in force. Under some disability policies, the amount and duration of benefits is determined based on whether a disabling condition is classified as an injury or sickness.

Click here to learn more about how your policy may treat disabilities due to sickness different than disabilities due to injury.

Social Security Offset Rider

See Offset Provision.

Surveillance

Surveillance is a tool commonly used by insurance companies to collect information that they can use to deny or terminate claims.

Click here for more information about how insurance companies use surveillance to deny or terminate benefits.

Termination of Benefits

Insurance companies can pay a claim for years, only to decide that an insured is no longer eligible for benefits. Signs that your long-standing claim may be targeted for termination include an increase in the frequency of requests for claim forms, a request for an independent medical examination or functional capacity examination, a re-assignment of your claim to a more senior claims analyst, and/or conducting surveillance, among others.

Click here for more information on disability claim denials and terminations.