Glossary - Disability Claims Management

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Glossary

A B C D E F G H I J L M N O P Q R S T V W [A-W]


Word	Definition

Accessibility	Accessibility: As required by the Americans with Disabilities Act, removal of barriers that would hinder a person with a disability from entering, functioning, and working within a facility. Required restructuring of the facility cannot cause undue hardship for the employer.



Accident, Industrial (Occupational)	Accident, Industrial (Cccupational): In workers' compensation, an unforeseen, unintended event that occurs in the course of an individual's employment and results in an injury or illness.



Accidental Bodily Injury	Accidental Bodily Injury: A bodily injury that is the direct result of an accident and not related to any other cause.



Active Employment	Active Employment: Working for an employer on a permanent full-time basis and paid regular earnings and performing the material duties of a regular occupation. An employee must be working the minimum number of hours as specified in the contract and the employee's work site must be at the employer's usual place of business, an alternative work site at the direction of the employer, or a location to which the job requires the employee to travel.



Actively At Work	Actively At Work: Performing all the material duties and required hours of a job in the location where the duties are normally carried out.



Activities of Daily Living (ADL)	Activities of Daily Living (ADL): The activities an individual needs to perform to live independently. These include bathing, dressing, toileting, transferring, continence and feeding.



Adjudication	Adjudication: In workers' compensation, the process of handling a claim, from first report through final resolution. In group disability benefit plans, the process of determining eligibility for benefit payment.



Age Discrimination in Employment Act (ADEA)	Age Discrimination in Employment Act (ADEA): A 1967 Federal law that prohibits employers with 20 or more employees from discriminating on the basis of age in hiring, job retention, compensation, and benefits. ADEA also sets requirements for the duration of employer-provided Disability benefits.



Americans with Disabilities Act (ADA)	Americans with Disabilities Act (ADA): A physical or mental impairment that substantially limits one or more of an individual's major life activities; also having a record of such an impairment or being regarded as having such an impairment.



Americans with Disabilities Act (ADA):	Americans with Disabilities Act (ADA): A 1990 federal law that prohibits discrimination against persons with disabilities in the terms and conditions of employment. Employers must provide reasonable accommodation for the physical or mental limitations of a qualified individual to enable him or her to perform the essential functions of a job.



Any Occupation	Any Occupation: In LTD plans, any gainful work or service for which an employee is reasonably qualified, taking into consideration his or her training, education, and experience. A minimum income standard is not typically specified, but administrative practice commonly requires 60% or pre-disability earnings.



Any Occupation Period	Any Occupation Period: The period during which employees will continue to receive LTD benefits as long as they cannot perform any job for which they are reasonably qualified by training, education, and experience; usually six to 30 months. See also own occupation period.



Appeals Process	Appeals Process: As mandated by ERISA, a procedure whereby individuals covered by an employer-sponsored benefit plan can appeal a benefit determination with which they disagree. The appeal must be filed within 60 days of receiving the determination. The employer or its agent (usually an insurance carrier or third-party administrator) must communicate its decision within 30 days of the filing of an appeal.



Attending Physician	Attending Physician: The physician responsible for the admitting and directing of care and services provided to a patient while in an acute, skilled or rehabilitation facility. See treating physician.



Attending Physician Statement (APS)	Attending Physician Statement (APS): A report, filled out the insured's physician documenting current and prior health history. An APS helps the insurance company in the evaluation process of approving an application or a claim.



Average Weekly Wage (AWW)	Average Weekly Wage (AWW): In workers' compensation, the wage used to determine the amount of temporary Disability benefits for which an employee is eligible. Calculation varies by state law.



Benefit Coordination	Benefit Coordination: see benefit integration.



Benefit Duration	Benefit Duration: The length of time that medical or STD/LTD benefits will be paid to an employee, as specified by the insurance contract or plan design. Federal requirements for benefits duration are contained in the Age discrimination in Employment Act (ADEA).



Benefit Integration	Benefit Integration: 1) Reduction of a scheduled benefit by amounts paid or available to an employee from other disability-related sources of income. For STD and LTD plans, other sources could include workers' compensation, government disability plans, disability benefits from pension plans, retirement benefits, and Social Security disability benefits both primary and family, also known as benefit coordination or offsets. 2) Interdependent administrative and benefit design provision of STD, LTD, WC, and other paid time off benefits to achieve cost savings, optimal medical treatment, and return to work.



Benefit Percentage	Benefit Percentage: Percent of weekly (short-term disability) or monthly (long-term disability) salary that will be replaced.



Board Certification	Board Certification: A status awarded by a professional association indicating that the health care practitioner has met specific standards of knowledge and clinical skill within a specified field. The board certification process usually involves passing a written and oral examination administered by the professional certification committee.



Broker	Broker: An individual who represents an insured in the solicitation, negotiation or procurement of insurance. An insurance broker does not represent insurance companies as agent but places orders with insurance companies.



California State Disability Insurance (SDI) Law	California State Disability Insurance (SDI) Law: Mandates a non-occupational, short- term disability plan funded through a tax-supported state fund; in effect since 1946. Employers may substitute a private, self-insured plan exceeding state fund standards; additional cost is funded by employer, employees, or both.



Case Management (Integrated)	Case Management (Integrated): Coordination of short and long-term disability, health care, workers' compensation, ergonomics, and return-to-work programs to improved care delivery, streamline claims administration, and return employees to work.



Ceding Company	Ceding Company: See reinsurance.



Census Data	Census Data: Information such as date of birth, sex, income, or occupation on persons eligible for or insured by a group policy; used to determine premium rates or benefits.



Chronic Disease	Chronic Disease: A condition whose symptoms may be ameliorated with treatment but the underlying condition cannot be cured.



Claim	Claim: 1) A demand to an insurer or third-party administrator by, or on behalf of, a covered person of disability or workers' compensation benefits requesting payment under the terms of the policy. 2) A written request by a health care provider to receive payment for services provided.



Claim, Closed	Claim, Closed: A claim under which all contractual benefits have been paid.



Claim, Controverted	Claim, Controverted: In workers' compensation, a claim that has been questioned in whole or part by the insurer, third-party administrator, or self-insured employer.



Claim, Incurred	Claim, Incurred: The dollar amount of an insurer's liability at a certain point in time: the sum of paid claims, open claim reserves, and incurred but unreported claim reserves, discounted for interest earnings.



Claimant	Claimant: An individual who submits a claim.



Confidentiality	Confidentiality: The degree of protection afforded individually identifiable health information. When sharing information and records about an individual, insurers and employers must respect an individual's right to privacy.



Contributory Insurance	Contributory Insurance: A type of employer-sponsored coverage for which the covered employee pays a portion of the premium cost. The same portion of any benefit received is tax-free to the employee.



Current Procedural Terminology (CPT)	Current Procedural Terminology (CPT): A list of descriptive terms and identifying codes for medical, surgical, and diagnostic services and procedures. Provides a uniform language for reporting and billing purposes.



Deductible	Deductible: The portion of a loss for which the policy-holder is responsible. In workers' compensation, the injured individual is generally not liable for a deductible.



Deductible Sources of Income	Deductible Sources of Income: Income from deductible sources listed in the plan which you receive or are entitled to receive while you are disabled. This income will be subtracted from your gross disability payment.



Dependent	Dependent: A spouse or unmarried child under age 19 (if a child is a full-time student in an accredited school, age 23 or 25 depending upon the provisions of the contract). Children can include biological, adopted, foster and step who are supported by the insured.



Diagnostic and Statistical Manual of Mental Disorders [Fourth Edition] (DSM-4)	Diagnostic and Statistical Manual of Mental Disorders [Fourth Edition] (DSM-4): A tool used by the medical and psychological communities to identify and classify behavioral, cognitive, and emotional problems according to a standard numerical coding system of mental disorders.



Dictionary of Occupational Titles (DOT)	Dictionary of Occupational Titles (DOT): A book of job classifications that specifies the duties of each job listed; maintained and updated by the U.S. Department of Labor as new jobs are created and technologies change.



Disability	Disability: A physical or mental impairment that prevents or restricts normal achievement. Something that hinders or incapacitates.



Disability Benefit	Disability Benefit: 1) Amount payable under a group disability (STD or LTD) plan to a covered employee who meets eligibility criteria typically between 50% and 70% of pre-disability income. Salary continuation plans often provide 100% of pre- disability income prior to eligibility for STD/LTD. 2) A provision added to a life insurance policy providing for a waiver of premium and sometimes payment of monthly income if the insured becomes totally and permanently disabled.



Disability Management	Disability Management: Programs that seek to prevent disability, reduce the cost impact of disability, and provide mechanisms to promote maximum functional recovery and return- to-work. Integrated disability management refers to those programs that are implemented across all disability plans (e.g., STD, LTD, WC, and salary continuation) in addition to, increasingly, group health plans.



Disability, Duration Guidelines	Disability, Duration Guidelines: Guidelines that describe the duration of different types of disabilities according to diagnosis, symptoms, severity, and occupational factors. Duration guidelines may be used to evaluate disabilities and forecast an expected return-to-work time frame, such as in duration control guidelines.



Disability, Earnings	Disability, Earnings: The earnings you receive while you are disabled and working, plus the earnings you could receive if you were working to your maximum capability.



Disability, Employer-Sponsored Plans	Disability, Employer-Sponsored Plans: A functional limitation that impedes the performance of material duties of an employee's customary work. Disabilities are usually classified as total (permanent total / temporary total) or partial (permanent partial / temporary partial).



Disability, Full Maternity	Disability, Full Maternity: If an insured employee becomes disabled as a result of a pregnancy or complications, the disability will be covered on the same basis as any other illness.



Disability, Individual with	Disability, Individual with: Under the ADA, a person who has a physical or mental impairment that substantially limits one or more of that person's major life activities, has a record of such impairment, or who is regarded as having such an impairment.



Disability, Maximum Benefit	Disability, Maximum Benefit: For disability benefits, the maximum dollar amount an insured will receive while disabled. For health benefits, the total dollar amount the insurer will pay on any given individual.



Disability, Maximum Benefit Duration	Disability, Maximum Benefit Duration: The longest period for which employer- sponsored disability benefits will be paid, provided that the employee remains continuously disabled. Typically, the lesser of the number of years until Social Security normal retirement age or the age specified in the plan.



Disability, Maximum Monthly Benefit	Disability, Maximum Monthly Benefit: The highest dollar amount that an employee who has been disabled will receive each month from the employer's LTD plan.



Disability, Pension	Disability, Pension: An annuity payable from a qualified pension plan to an eligible employee who becomes disabled before normal retirement age. May be paid as a supplement to another employer-sponsored disability benefit plan or as a reduced pension.



Disability, Permanent Partial	Disability, Permanent Partial: A disability in which some portion of earning power is lost, and the loss is expected to last for the individual's lifetime.



Disability, Permanent Total	Disability, Permanent Total: A disability in which all earning power is lost, and the loss is expected to last for the individual's lifetime. In many states, workers' compensation laws specify certain injuries as permanent total disabilities even if the injured person is able to do some work. Compensation may be limited by time or amount, or it may run for life.



Disability, Social Security	Disability, Social Security: The inability to engage in any substantial gainful activity because of a medically determinable physical or mental impairment that can be expected to result in death or that lasts or can be expected to last for 12 months or more.



Disability, Temporary Partial	Disability, Temporary Partial: A disability in which some portion of earning power is lost for a period of time, but from which complete recovery is expected. Benefits are generally based on a percentage of the difference between the person's pre- disability wage and what he or she can earn during disability.



Disability, Temporary Total	Disability, Temporary Total: A disability in which all earning power is lost for a period of time, but from which complete recovery is expected. Benefits are payable until the individual returns to employment at some level of pre-disability earnings.



Disability, Workers' Compensation	Disability, Workers' Compensation: A physical or psychological condition that occurs in or results from the workplace and that actually or presumptively results in a loss of earning power. Disabilities may be total (permanent total / temporary total) or partial (permanent partial / temporary partial).



Disease Management	Disease Management: A coordinated care approach focused on prevention, early identification, and intervention in the chronic disease process. Services are typically provided by employer-sponsored health plans, contracted or "carve out" provider groups, or through the employer's occupational health facility. By controlling factors that determine the early course of a chronic condition, disease management proponents attempt to show that such programs improve individual health status, control medical costs, and reduce the incidence of work limiting disability.



Eligibility Date	Eligibility Date: The day on which an employee becomes eligible for insurance, after completing a plan's waiting period.



Eligible Survivor	Eligible Survivor: In LTD plans, a deceased employee's surviving spouse; if no spouse survives, then the employee's children under a certain age (e.g. 25)



Elimination Period	Elimination Period: The number of consecutive days an employee must be disabled before LTD benefits become payable (typically, 90 or 180 days). Also known as benefit waiting period and qualifying period. In some plans, employees are allowed to work during the elimination period; see residual.



Employee	Employee: A citizen or permanent resident of the United States or Canada who is in active employment in the United States with the Employer unless an exception is applied for and approved in writing by VPA.



Employee Assistance Program (EAP)	Employee Assistance Program (EAP): Employer-sponsored program designed to help employees whose job performance is being adversely affected by personal problems. May involve wellness and prevention efforts, counseling, and control of specific conditions (e.g., alcoholism or smoking). Some employers use EAP's to address the psychological aspects of disabling injuries or illnesses.



Employee Retirement Income Security Act (ERISA)	Employee Retirement Income Security Act (ERISA): The main purpose of the Employee Retirement Income Security Act is to ensure that employees receive the pension and other benefits promised by their employers. ERISA sets uniform minimum standards to assure that employee benefit plans are established and maintained in a fair and financially sound manner. In addition, employers have an obligation to provide promised benefits and satisfy ERISA's requirements for managing and administering private pension and welfare plans. Title I of ERISA requires persons and entities who manage and control plan funds to: ·• Manage plans for the exclusive benefit of participants and beneficiaries; ·• Carry out their duties in a prudent manner and refrain from conflict-of-interest transactions expressly prohibited by law; ·• Comply with limitations on certain plans' investments in employer securities and properties; ·• Fund benefits in accordance with the law and plan rules; ·• Report and disclose information on the operations and financial condition of plans to the government and participants; ·• Provide documents required in the conduct of investigations to assure compliance with the law. ERISA supersedes almost all state laws that affect employee benefit plans and has thus created a single federal standard for employee benefit.



Employer	Employer: The Policyholder: which includes any division, subsidiary or affiliated company named in the policy.



Employer's First Report of Injury	Employer's First Report of Injury: A state-required notice of the details of an industrial accident or occupational disease; must be filed by the employer or its agent with the workers' compensation insurance carrier and, in most cases, also with the state workers' compensation agency.



Enrollment	Enrollment: The process of selecting and signing up as a member of a health or disability plan.



Essential Functions	Essential Functions: As defined by the Americans with Disabilities Act, the fundamental job duties of the position that an individual with a disability holds or seeks. These are activities that every incumbent in a given job must perform. See also marginal functions.



Evidence of Insurability	Evidence of Insurability: Statement or proof of an individual's medical history, which determines his or her acceptability for coverage.



Examiner	Examiner: Person responsible for the adjudication of disability claims.



Experience	Experience: The financial status of an insured group's claim activity relative to the insurer or self-funding employer. "Good experience" indicates that claims payments are lower than expected; "bad experience" indicates the opposite.



Experience Data	Experience Data: History of premiums, incurred claims, paid claims, open claims, closed claims, plan changes, rates, and changes in number of covered individuals for a group.



Explanation of Benefits (EOB)	Explanation of Benefits (EOB): A statement mailed to a member or covered insured explaining how and why a claim was or was not paid; the Medicare version is called an EOMB.



Family and Medical Leave Act (FMLA)	Family and Medical Leave Act (FMLA): A 1993 federal law requiring employers with more than 50 employees to provide eligible workers up to 12 weeks of unpaid leave for birth, adoptions, foster care placement, and illnesses of employees and their families.



FAS 112	FAS 112: An accounting standard issued by the Financial Accounting Standards Board that prescribes how employers must account for post-employment benefits, including workers' compensation. Employers must recognize the future liability of disability claims and any associated medical claims as soon as they are incurred.



Federal Employees' Compensation Act (FECA)	Federal Employees' Compensation Act (FECA): Legislation that provides coverage similar to workers' compensation benefits for US government employees; administered by the Department of Labor.



Federal Insurance Contributions Act (FICA)	Federal Insurance Contributions Act (FICA): Federal Insurance Contributions Act (FICA) - The enabling legislation for the US Social Security tax system.



Functional Capacities Analysis	Functional Capacities Analysis: An evaluation of an employee or prospective employee's ability to perform the range of activities that are considered essential to job performance. Typically conducted by an occupational or physical therapist.



Grace Period	Grace Period: The period of time following the premium due date during which premium payment may be made.



Hawaii Temporary Disability Insurance (TDI) Law	Hawaii Temporary Disability Insurance (TDI) Law: Mandates a non-occupational, short-term disability plan funded by employers; in effect since 1969. Claims must be adjudicated in Hawaii. Employers may substitute a private, insured or self-insured plan at least equal to statutory requirements; additional cost is funded by employer, employees, or both. Certain existing plans are also permitted as alternatives.



Incurred But Not Reported (IBNR)	Incurred But Not Reported (IBNR): An insurer's estimate of costs associated with claims that have not yet been submitted for payment, based on studies of prior lags in claim submissions. Used to set claim reserves.



Indemnity	Indemnity: In workers' compensation, the benefit paid to replace lost wages; generally a tax-free replacement of two-thirds of the pre-disability wage, up to a dollar maximum.



Independent Medical Evaluation	Independent Medical Evaluation: A medical examination carried out by a physician other than the one treating a claimant; used to collect additional medical or functional capacity information, verify diagnoses and treatment plans, determine continued benefit eligibility, and resolve disputes relating to disability or workers' compensation claims.



Individual Disability Plan	Individual Disability Plan: A type of coverage sold directly to individuals by insurance companies and other financial institutions. A statement of health is typically required; premiums are usually age-sensitive; and benefits are based on the selected Plan design and level of payment.



Injury	Injury: A bodily injury that is the direct result of an accident and not related to any other causes that occurred after the effective date of the policy.



Insured	Insured: Any person covered under a plan.



Integrated Benefits	Integrated Benefits: A system whereby the claims processing, payment, case management, information management, and return to work functions of sick pay/salary continuance, STD, LTD, and WC are integrated in order to achieve administrative savings and optimal return-to-work outcomes. The integration is typically achieved through a central administrative function managed by the employer but insurer and TPA based programs have gained popularity in recent years. Increasingly, group health benefits are also being included in integrated benefit designs.



International classification of Diseases	International classification of Diseases, ninth edition [Clinical Modification] (ICD-9- CM): A list of diagnoses and identifying codes used by physicians and other health care providers. The coding and terminology provide a uniform language that permits consistent communication on claim forms.



Job Analysis	Job Analysis: Identification of the components of a job in order to ascertain the skills required for successful performance; components used include physical demands, mental demands, stress factors, environmental characteristics, and hazards.



Job Modification	Job Modification: The development of medically appropriate ways for employees with disability-related restrictions to perform their regular jobs.



Leave of Absence	Leave of Absence: A temporary absence from active employment for a period of time that has been agreed to in advance in writing by the Employer.



Light Duty	Light Duty: see transitional work.



Longshoremen and Harbor Workers Act	Longshoremen and Harbor Workers Act: Federally administered legislation that provides coverage similar to workers' compensation benefits for individuals in the named occupations.



Long-Term Disability (LTD) Plan	Long-Term Disability (LTD) Plan: Benefit plan that replaces a portion of income (usually 50%, 60%, or 66-2/3%) lost because of an injury or illness that lasts for an extended period of time and prevents an employee from performing all the material duties of his or her job. After a waiting period (e.g., 90 or 180 days), benefits are payable until the employee retires or reaches a specified age, provided the disability is continuous.



Material Duties	Material Duties: In LTD plans, the basic and essential requirements of a job. To be considered disabled, employees must be unable to perform material duties, not incidental or insignificant tasks.



Maximum Benefit	Maximum Benefit: For disability benefits, the maximum dollar amount an insured will receive while disabled. For health benefits, the total dollar amount the insurer will pay on any given individual.



Maximum Benefit Duration	Maximum Benefit Duration: The longest period for which employer-sponsored disability benefits will be paid, provided that the employee remains continuously disabled. Typically, the lesser of the number of years until Social Security normal retirement age or the age specified in the plan.



Maximum Medical Improvement (MMI)	Maximum Medical Improvement (MMI): The point at which an employee who has been disabled reaches a plateau in recovery, so that any remaining impairment is considered to be permanent. In workers' compensation, MMI triggers the transition from temporary to permanent Disability benefits.



Maximum Monthly Benefit	Maximum Monthly Benefit: The highest dollar amount that an employee who has been disabled will receive each month from the employer's LTD plan.



Medical Necessity	Medical Necessity: Services/procedures which are approved in accordance with recognized medical standards as effective and appropriate and are essential to retard, reduce or eliminate an impairment.



Medical Only	Medical Only: A type of workers' compensation claim that involves no wage replacement (because no work time was lost) but only reimbursement of medical expenses.



Medical Record	Medical Record: A written or electronic account of a patient's medical history, current illness, diagnosis, details of treatments, chronological progress notes, and discharge recommendations. This is a legal document the patient is entitled to read and is authenticated by the physician's signature. There are strict rules regarding the confidentiality of the medical record.



Medicare	Medicare: Federally administered health insurance plan intended primarily for person age 65 and older; also available to individuals with disabilities after they have received Social Security Disability Insurance benefits for 24 months. Medicare has two parts, part A covers hospital costs; part B covers medical expenses.



Mental Illness	Mental Illness: A psychiatric or psychological condition regardless of cause such as schizophrenia, depression, manic depressive or bipolar illness, anxiety, personality disorders and/or adjustment disorders or other conditions. These conditions are usually treated by a mental health provider or other qualified provider using psychotherapy, psychotropic drugs, or other similar methods of treatment.



Mental Illness Limitation	Mental Illness Limitation: Limit on the period of time (often 24 months) over which LTD benefits will be paid when an employee is disabled as a result of mental, emotional, or nervous condition that is being treated on an outpatient basis. The limitation does not apply while the individual is confined to a hospital or institution.



Minimum Monthly Benefit	Minimum Monthly Benefit: The lowest dollar amount an employee who has been disabled will receive each month from the employer's LTD plan. Some plans guarantee a minimum benefit, regardless of income received from other sources.



Monopolistic State Fund	Monopolistic State Fund: In certain states, a fund set up as an agency of a state government, from which all employers who are not self-insured or covered by group self- insurance are required to purchase workers' compensation insurance.



Morbidity	Morbidity: The expected incidence and severity of illness and accidents in a specified group.



National Association of Insurance Commissioners (NAIC)	National Association of Insurance Commissioners (NAIC): Organization for the chief administrators of all state insurance commissions.



New Jersey Temporary Disability Benefits (TBD) Law	New Jersey Temporary Disability Benefits (TBD) Law: Mandates a non-occupational, short-term disability plan funded through a tax-supported state fund; in effect since 1950. Employers may substitute a private, insured of self-insured plan equaling or exceeding state fund standards. Certain existing plans are also permitted as alternatives.



New York Disability benefits Law (DBL)	New York Disability benefits Law (DBL): Mandates a non-occupational, short-term disability plan funded by employers; in effect since 1950. Employers may substitute a private, insured or self-insured plan equaling or exceeding state benefits; additional cost is funded by employer, employees, or both. Certain existing plans are also permitted as alternative.



Non-Occupational Plan	Non-Occupational Plan: Any employer-sponsored disability benefit plan that provides income replacement for employees whose disability is not caused by their employment. These plans may also provide for supplements to workers' compensation benefits in the event of occupational injuries or illnesses.



Occupation	Occupation: Any meaningful work for which an employee is reasonably qualified in terms of training, education, and experience.



Occupational Injury	Occupational Injury: An injury that occurs in the course of work or a health impairment caused by conditions in the work environment.



Occupational Safety and Health Act (OSHA)	Occupational Safety and Health Act (OSHA): A federal law that sets national standards for health and safety conditions in the work place. The act also provides for compiling and reporting of statistics on occupational illnesses and injuries.



Old Age, Survivors, Disability, and Health Insurance (OASDHI)	Old Age, Survivors, Disability, and Health Insurance (OASDHI): Benefits provided under the US Social Security program.



Omnibus Budget Reconciliation Act (OBRA) of 1993	Omnibus Budget Reconciliation Act (OBRA) of 1993: Federal legislation that limits the amount of compensation that can be paid to employees covered by LTD plans funded through VEBA (voluntary employees' beneficiary association) trusts. Any such plan with participants earning more than $150,000 could lose its tax-exempt status.



Other Income Sources	Other Income Sources: Income and benefits other than the employer-provided benefit received by an employee who has been disabled, or by his or her family; e.g., payments from Social Security, workers' compensation, mandated state disability plans.



Own Occupation	Own Occupation: In LTD and STD plans, the job functions that an employee regularly performed before incurring a disability.



Own Occupation Period	Own Occupation Period: The period during which employees will continue to receive LTD or STD benefits as long as they cannot perform their regular job; usually six months. See also any-occupation period.



Peer Review	Peer Review: The evaluation of the clinical practice activities as well as the clinical outcomes of one health care professional by others of the same specialty and geographic region.



Per Member Per Month (PMPM)	Per Member Per Month (PMPM): The method by which most managed care organizations account for revenue and expenses.



Physiatrist	Physiatrist: A physician who is board-certified in physical medicine and rehabilitation.



Physical Capacity	Physical Capacity: The capability of an employee to perform work activities and job tasks.



Physical Medicine and Rehabilitation	Physical Medicine and Rehabilitation: The medical practice of diagnosing, treating, preventing, and rehabilitating conditions that result in physical impairments and disabilities. Also known as physiatry.



Policyholder	Policyholder: The Employer to whom the policy is issued.



Pre-Disability Earnings	Pre-Disability Earnings: The amount of an employee's wage or salary covered by a plan on the date disability began; usually excludes overtime pay, bonuses, commissions, and any other extra pay. In STD plans, also called basic weekly earnings. In LTD plans, also called basic monthly earnings or covered earnings. After the first year of disability, the covered earnings may be increased by an annual percentage (indexed) to keep pace with inflation.



Preexisting Condition	Preexisting Condition: Illness or injury for which an employee has received medical treatment or consultation before the effective date of coverage under a disability plan.



Preexisting Condition Limitation	Preexisting Condition Limitation: Plan Provision that excludes or reduces Disability benefits for any illness or injury for which an employee received medical treatment or consultation within a specified time period before being covered under a disability plan.



Premium	Premium: The periodic payment (e.g., monthly, quarterly) required to keep an insurance policy in force.



Premium, Annualized	Premium, Annualized: The price of coverage for one year; the premium for one period multiplied by the number of periods in the policy year.



Premium, Earned	Premium, Earned: That part of a premium applicable to the elapsed portion of the policy term (the period of time for which the insurer has already provided coverage).



Premium, Initial	Premium, Initial: Premium deposit paid when applying for a policy; applied against the first period's premium when it is determined.



Primary Care Physician	Primary Care Physician: A physician trained in one or more of the following areas: family medicine, general practice, general internal medicine, and pediatric medicine. Some health plans include obstetrics-gynecology as one of the types of primary care physicians.



Primary Integration	Primary Integration: The LTD benefit is reduced, dollar for dollar, by social security benefits paid or payable to the insured because of the worker's disability. This does not include benefits payable to the eligible spouse and/or children.



Providers	Providers: A broad term referring to the licensed or certified health care professionals and organizations that provide care to HMO members. Providers can be independent professionals in private practice or they can be members of an organized group, such as multi-specialty medical group. Common providers in managed care include hospitals, medical groups, home care companies, skilled nursing facilities, medical equipment companies, primary care physicians, and specialty physicians.



Puerto Rico Disability Benefits (PRDB) Law	Puerto Rico Disability Benefits (PRDB) Law: Mandates a non-occupational, short-term disability plan funded through a tax-supported state fund; in effect since 1969. Employers may substitute a private, insured or self-insured plan equaling or exceeding state benefits; additional cost is funded by employer, employees, or both.



Qualified Individual With a Disability	Qualified Individual With a Disability: As defined by the American with Disabilities Act, one who can perform the essential functions of a job with or without reasonable accommodations. The qualified worker must meet the employer's job requirements for education, work experience, job skills, and training.



Railroad Retirement Act	Railroad Retirement Act: Federally administered legislation that provides coverage similar to workers' compensation benefits for railway employees.



Reasonable Accommodation	Reasonable Accommodation: As required in the Americans with Disabilities Act, modifications or adjustments to the work environment - e.g., job restructuring, equipment modifications - that enable a qualified individual with a disability to perform the essential functions of a job.



Recurrent Disability	Recurrent Disability: A disability which is related to or due to the same cause(s) of a prior disability for which a monthly benefit was payable. Typically, the disability must recur within 6 months after returning to work for the insured to be eligible for a resumption of benefits.



Reimbursement Agreement for SSDI	Reimbursement Agreement for SSDI: In employer sponsored programs, a written promise by a claimant to reimburse the insurer for any overpayment of disability benefits that may be due to the awarding of SSDI.



Reinsurance	Reinsurance: The acceptance by one insurance company of a portion of a risk underwritten by another company. In a type of reinsurance called facultative, the reinsurer retains the right to reject any specific risk presented by the reinsured.



Residual	Residual: In LTD plans, a provision allowing an employee who has been totally disabled to resume work on a trial basis, while continuing to satisfy the elimination period.



Residual, Zero-Day	Residual, Zero-Day: In LTD plans, a provision allowing an employee who has been partially disabled to work on a trial basis immediately, while continuing to satisfy the elimination period.



Return-To-Work Program	Return-To-Work Program: An organized effort by an employer to assist recovering employees in assuming constructive job duties. Programs may include temporary limited hours, modified job duties, or transitional jobs as well as permanent accommodations including modified or alternate jobs.



Rhode Island Temporary Insurance (TDI) Law	Rhode Island Temporary Insurance (TDI) Law: Rhode Island Temporary Disability Insurance (TDI) Law - Mandates a non-occupational, short-term disability plan funded through a tax-supported state fund; in effect since 1942. Employers may not substitute a private plan.



rogression of Disability Benefits (PODB)	rogression of Disability Benefits (PODB): The predictable and progressive movement of individuals with disabilities through a system of income replacement benefits (STD, LTD, WC) resulting in their movement into the Social Security disability system (SSDI or SSI).



Salary Continuation	Salary Continuation: An employer plan that provides a payment to salaried employees during period of injury and/or illness ranging from several weeks to several months. The benefit amount may be controlled by length of service, job performance, and/or union contracts. This discretionary benefit can be coordinated with workers' compensation and other disability benefits so as not to exceed the base salary of the employee. Also often referred to as sick leave.



Second Injury Fund	Second Injury Fund: In workers' compensation, a program administered by the state to pay for the covered disabilities of injured workers with preexisting conditions. The agency is generally funded by assessments on private underwriters of workers' compensation insurance.



Self-Funding	Self-Funding: See self insurance.



Self-Insurance	Self-Insurance: A process whereby an employer covers risks by establishing reserves for future losses in lieu of purchasing insurance protection. Also known as self-funding.



Short-Term Disability (STD) Plan	Short-Term Disability (STD) Plan: A plan that replaces a portion (usually 50%, 60%, or 66-2/3%) of income lost because of an injury or illness that prevents an employee from performing the duties of his or her job. Benefits are usually paid following a waiting period (e.g., seven days) and may continue for various periods: one week, 13 weeks, 26 weeks, 52 weeks, or until LTD benefits become payable.



Sick Pay	Sick Pay: An uninsured benefit often paid to hourly workers for a period of illness. The benefit period typically ranges from five to 20 days a year; any unused time at year-end can often be banked. The benefit amount is usually 100% of earnings.



Social Security Disability Insurance (SSDI):	Social Security Disability Insurance (SSDI): A system of federally provided payments to eligible workers (and, in some cased, their families) when they are unable to continue working because of a disability. Benefits begin with the sixth full month of disability and continue until the individual is capable of substantial gainful activity. (See reimbursement agreement for SSDI).



Social Security Normal Retirement Age (SSNRA)	Social Security Normal Retirement Age (SSNRA): The age at which unreduced Social Security benefits are payable. As defined by a 1983 amendment to the Social Security Act, that age is 65 for individuals born before 1938, 66 for those born from 1938 to 1954, and 67 for those born after 1954.



State-Mandated Disability Plans	State-Mandated Disability Plans: Required minimum STD plans for workers in the states of California, Hawaii, New Jersey, New York, Rhode Island, and the Commonwealth of Puerto Rico. Most plans provide modest coverage (e.g., 50% replacement up to a maximum of $145 a week), with benefit durations of at least 26 weeks.



Statute / Statutory	Statute / Statutory: 1. An act of the legislature of a state or country, declaring, commanding, or prohibiting something; a positive law; the written will of the legislature expressed with all the requisite forms of legislation; used in distinction from common law. See Common law, under Common. Statute is commonly applied to the acts of a legislative body consisting of representatives. In monarchies, legislature laws of the sovereign are called edicts, decrees, ordinances, rescripts, etc. In works on international law and in the Roman law, the term is used as embracing all laws imposed by competent authority. Statutes in this sense are divided into statutes real, statutes personal, and statutes mixed; statutes real applying to immovables; statutes personal to movables; and statutes mixed to both classes of property.



Statutory, Reserve	Statutory, Reserve: An actuarially determined bookkeeping liability which represents the minimum amount of money an insurer must set aside to meet future claims and obligations, as calculated under the state insurance code.



Supplemental Security Income (SSI)	Supplemental Security Income (SSI): A program of the Social Security Administration that pays monthly benefits to eligible workers with disabilities who fall fellow a certain asset and income level.



Survivor Benefit	Survivor Benefit: Amount payable to an employee's eligible survivors following the employee's death due to disability. Payment may be in a lump sum (e.g., three times the employee's last monthly LTD benefit) or a number of monthly payments (e.g., six months).



Third Party Administrator (TPA)	Third Party Administrator (TPA): A professional organization hired to provide plan administration for client employees and their benefit plans. Typical duties include: processing claims, paying providers, and providing benefit & eligibility information. These are a few of the administrative duties that a TPA performs.



Transferable skills analysis (TSA)	Transferable skills analysis (TSA): n evaluation of an employee who has been disabled to determine employability and job placement potential, and to develop a vocational training plan.



Transitional Return-To-Work Program	Transitional Return-To-Work Program: A program to enable employees who have been disabled to return to modified work with retraining options. The on-site program coordinates the efforts of company-based physical therapists, physicians, department supervisors, occupational health nurses, and supplier-provided disability management services.



Treating Physician	Treating Physician: The medical practitioner who has primary responsibility for the care of a claimant. Also known as attending physician.



Vocational Rehabilitation	Vocational Rehabilitation: A process initiated as early as possible for an employee who has been disabled and may require a different job or career as a result. May include vocational assessment, labor market surveys, developing alternative work plans, retraining, and assistance with job-seeking skills.



Voluntary Employees' Beneficiary Association (VEBA)	Voluntary Employees' Beneficiary Association (VEBA): A tax exempt fund set up to provide non-retirement benefits to a group of employees and their dependents. A 501 (c) (9) trust is often used as the funding vehicle.



Waiver of Premium	Waiver of Premium: Exemption of an employee from responsibility for LTD premium payments during any period in which a disability benefit is payable. Wellness program - Any of a range of employer-sponsored activities designed to increase employees' overall quality of life, prevent accidents and ill health, and reduce the associated costs. May include programs for fitness, smoking cessation, nutrition and weight management, stress management, blood pressure screening, health risk appraisals, etc.



Work Incentive Improvement Act of 1999	Work Incentive Improvement Act of 1999: Federal law that provides for continuation of Medicare benefits when SSDI recipients return to work. Also provides for state demonstration projects for Medicaid continuation/buy-in arrangements for disabled employees and rehabilitation vouchers.



Workers' Compensation	Workers' Compensation: A system of providing for the cost of medical care and weekly payment to employees injured on the job or to dependents of those killed in industry in which no-fault liability is imposed on the employers. In return, employees are generally prohibited from using employers, even if the disabling event was due to employer negligence. US government employees, harbor works, and railroad workers are not covered by state workers' compensation laws, but instead by other federally administered laws.

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