Originally Published June 15, 2015
The term “disability” or “disabled” is heard
frequently, especially when discussing a medical condition such as
Hepatitis B or C, which tend to be progressive in their symptoms and
can lead to an inability to work.
The word is used in so many
contexts, however, that it has become virtually generic to mean any type
of limitation. It really has no special meaning other than describing a
condition of some sort that prevents a person from doing something.
Is lack of height a disability? It is if you stand 5’ 6” and you are trying out for the NBA.
Does an infected hangnail
constitute a disability? Probably not. Then again, if you are a
surgeon, it could be “disabling” – preventing him or her from
Missing an arm or leg
certainly seems to be a disability, but many people can perform their
jobs perfectly well in that situation.
Clearly, then, when the term
“disability” or “disabled” is used for a specific purpose, for example,
to pay benefits to someone who is “disabled,” a clear definition of the
term must be established. Social Security, disability insurance
policies, and other programs for people with “disabilities” must define
the term, and each seems to put their own slight twist on how they
define it. That is why your doctor’s letter stating that you are disabled will not automatically get you disability benefits.
Each party trying to determine your disability status must see that
you meet their own definition of disability through the medical record
and, occasionally, through physical examination.
Totally Disabled/Total Disability
First, be aware that in this context, “disabled” and
“disability” are really shorthand for what Insurance companies and the
Social Security Administration actually refer to as “Total Disability”
and “Totally Disabled.” All apply specific definitions to the term and
it is important to know the specific definition as that is the
yardstick with which a claimant’s medical condition is measured to see
if they qualify for benefits.
Social Security defines “totally disabled” as:
“You have a serious, DOCUMENTED, physical or mental health condition;
Which prevents you from being able to earn Substantial Gainful Activity ($1,090/month in 2015); and,
That condition is expected to last at least twelve months or result in death.”
This is a very detailed
definition, yet it can be one of the most difficult to meet. Notice
that Social Security immediately eliminates coverage for brief periods
of disability by including the “12 month” limitation. The disability
does not have to have lasted 12 months, only that it is expected to
last that long. Also an exception is made for those with an illness that
is terminal and can lead to death within twelve months.
Under Social Security rules, you
are not necessarily disabled just because you can’t perform the
occupation you used to have. Instead, if you can’t do your prior job,
they will look to see if there is another occupation for which you
might qualify either by past experience or training or education.
Unfortunately, they will not find you that job; they will just list some
occupations they feel you could perform.
For example, they may expect a
35 year old with a college degree, who can no longer perform his prior
job, to be able to move to another job that he is able to do, both
physically and mentally. In another case, a 55 year old who has only a
high school diploma and spent his entire career in one, relatively
unskilled job may be eligible for benefits just because he can no longer
perform the only job he is qualified through education or experience
Private Disability Insurance
Benefits paid under either employer provided
disability plans or individually purchased disability policies are all
paid according to the terms of the disability plan document or the
insurance contract. Each policy will define “totally disabled/totally
disability” in the contract so anyone contemplating leaving work due to
disability should know how the particular plan defines it.
Although each plan’s definition
may vary, there are some basic provisions that are usually included in
the definition in one form or another:
Loss of income
– Some plans define disability as “due to a medical condition, the
claimant has lost at least twenty percent of his prior earnings.” Such
plans will only pay full benefits if the claimant has lost 80% or more
of his income. If the income loss is between 20% and 80% of prior
earnings, then only a proportionate benefit is paid. Some plans use
this provision without an “inability to work” provision; most, however,
will use a combination of the two effectively requiring inability to
work AND a loss of income.
Under medical care
– Many definitions also include a requirement that the claimant be
under the ongoing care of a physician, although some contracts will
waive that requirement if there is nothing medically to be done by
The way insurance companies
define “Totally Disabled” has a profound effect on who will get
benefits, and knowing what definition a claimant has to meet should
help him or her and his or her physician clearly document the medical
record to reflect the claimant’s condition in the light of the
definition used. Some older contracts written by professionals such as
doctors and dentists defined disability so narrowly that they were
obligated to pay full benefits even though the claimant was able to do
other types of full-time employment. The days when those policies
were written are long gone.
Sometimes called Residual
Disability, is not defined or used by Social Security. Their disability
programs, both Social Security Disability (SSD) and Supplemental
Security Income (SSI) have programs for persons “working while
disabled” that effectively provide coverage for a partial disability.
Note that the rules for working while disabled vary dramatically
between SSD and SSI.
Partially Disabled is also used
in disability insurance plans, both individual Disability Income and
group Long Term Disability. Usually, they provide a proportionate
benefit to the claimant based on the amount of wages they are able to
earn compared with what they earned prior to disability, adjusted for
inflation. For example a person who can do some work and earn 40% of
their prior earnings would be eligible to get 60% of the total
disability benefit. At least that is a “typical” partial disability
provision. The contract should be checked as the provision can vary.
This is really a non-term when referring to
disability benefits. Other than Social Security’s requirement of
lasting at least one year, benefit plans are more concerned with how
total the disability is not how long it will last. All plans require
that the person remain disabled and may terminate benefits if a medical
review shows the disability has ended.
However, the term “permanently
disabled” is occasionally used in some pension plans as the grounds for
a disability retirement designation. To be honest, to say someone is
permanently disabled is simply a prediction that may or may not be
true. No disability plan makes you promise never to work again.
You Can Help
Now that you know what yardstick a program uses to
measure whether or not you are disabled, you can see why they will not
accept your physician’s opinion of your condition. You also can see why
it is important that you discuss the disability definition of your
plan with your doctor before, well before if possible, filing a
While you and your physician
usually focus on finding the diagnosis of your condition and methods of
treatment, the disability carrier wants to know what symptoms your
conditions cause that prevent you from doing whatever occupation the
definition calls for. Unfortunately, in today’s healthcare that limits
time spent with doctors – instead there are computerized records that
just require checking boxes and filling in blanks; there is little
opportunity for a detailed description of your symptoms, much less
details of their severity and frequency, and how they limit your
ability to function.
Therefore, it is extremely
important for people who may someday have to file for disability to
provide such details to your physician regularly, and insist that they
be included in the medical record. Take a written summary with you each
time you see the doctor. List what symptoms you experienced and how
they affected your ability to perform tasks at home and at work.
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