Chapter 16 Disability Income Insurance and Disability Benefit Programs

Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved 1

Chapter 16

Disability Income Insurance and Disability Benefit Programs

Insurance Handbook for the Medical Office

13th edition

Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved

Disability Income Insurance and Disability Benefit Programs

1. Define terminology and abbreviations pertinent to disability insurance and disability benefit programs.

2. Describe benefits and exclusions contained in individual and group disability income insurance.

3. Name federal disability benefit programs.4. Differentiate between SSDI and SSI.

2

Lesson 16.1


Disability Income Insurance and Disability Benefit Programs (cont’d)

5. State eligibility requirements, benefits, and limitations of SSDI and SSI.

6. Explain disability benefit programs for disabled active military personnel, veterans, and their dependents.

7. Name states that have state disability insurance plans.

8. State eligibility requirements, benefits, and limitations of state disability plans.

9. Explain voluntary disability insurance plans. 3

Lesson 16.1


Disability Income Insurance and Disability Benefit Programs (cont’d)

10. Describe topics and contents of a medical report.

11. List guidelines for federal disability claims.12. Explain procedures for state disability claims.13. Recognize forms used for processing state

disability plans.

4

Lesson 16.1


Disability Claims Disability income insurance Provides benefits under certain

conditions when the insured is unable to work due to illness, disease, or injury

Does not provide benefits if the insured is unable to work as a result of a work-related event

5


History 1880s – emergence of disability income

policies for accident and illness early 1900s – first noncancelable policy 1956 – Congress extended Social

Security program to disabled adults over 50 years old

1965 – Social Security program expanded to cover workers regardless of age

6


Disability Income Insurance Individual

Provides specific income if disabled Insured pays premiums Medical expenses not covered Disability must not be work-related Insured must meet specific policy criteria

7


Disability Income Insurance Waiting period

Time from beginning of disability to beginning of first benefit payment

Benefit period Maximum span of time that benefit will be

paid to the disabled party

8


Disability Income Insurance Benefits

Residual benefits• Benefits are paid if disability is partial or limits the

capacity to work full-time Supplemental benefits

• Specific provisions may increase payments Accidental death and dismemberment

benefit• Special clause addresses accidents that result in

death or permanent disability

9


Disability Income Insurance Types of disability

Total disability• Person cannot perform most normal work duties

Partial disability• Person cannot perform all normal work duties

Temporary disability• Person cannot perform all normal work duties for

a limited period of time

10


Disability Income Insurance Clauses

Policies can be guaranteed renewable or noncancelable, with a waiver of premium

Exclusions Examples are preexisting conditions, mental

conditions, or other disabilities AIDS/HIV

Consent and notice form is needed for testing

11


Disability Income Insurance Group

Some employers offer as an optional benefit Contracts are between the insurer and the

employer Employer pays premiums, with or without

employee contributions Policy terminates when employee leaves the

company

12


Federal Disability Programs Disability benefit programs

Social Security Disability Insurance (SSDI) Supplemental Security Income (SSI) Civil Service Retirement System (CSRS) Federal Employees Retirement System

(FERS) Armed Services Disability Veterans Affairs (VA) Disability Program

13


Disability Benefit Programs Social Security Disability Insurance

Long-term plan provides benefits to workers and self-employed who meet eligibility criteria

Insured also may be eligible for Medicare after 24 months

Converts to retirement benefits at age 65

14


Disability Benefit Programs Supplemental Security Income

Long-term disability program provides benefits to adults and children regardless of employment history

Many persons also qualify for Medicaid Benefits are intended for those with limited

income and few other resources

15


Disability Benefit Programs Civil Service and Federal Employees

Retirement System Disability Benefits are payable for life to individuals

who qualify. Armed Services Disability

Benefits are payable for life if disability occurs or is aggravated while person is on active duty.

16


Disability Benefit Programs Veterans Affairs Disability

Service-connected disability is eligible for outpatient treatment if filed within 1 year of injury.

Non-service-connected disability may be eligible for same benefits if criteria are met.

17


State Disability Insurance Nonindustrial disability insurance

programs exist in only five states and Puerto Rico

To fund the programs, a percentage of wages is deducted from paychecks, or the employer pays the plan costs

Eligibility ceases upon retirement

18


State Disability Insurance Restrictions

Time limit for filing exceeded Condition covered under workers’

compensation insurance Unemployment benefits beyond a specified

amount Employer has a voluntary disability plan and

does not participate in state plan

19


Voluntary Disability Insurance Designed for persons who reside and

work in states without state disability insurance programs

Local private insurance carrier arranges coverage

If disabled, the person receives fixed weekly or monthly income, usually for 6 months

20


Claims Submission Guidelines Disability income claims

Person must provide completed proof of loss to establish disability

Attending physician usually must complete portions of this form

Medical report may be attached to the form for additional explanation of disability and treatment

21


Disability Income Claims Federal disability claims

SSA has teledictation service for physician to dictate medical report directly over the phone

Only data less than 1 year old is allowed Prognosis should be based on medical

findings Claim should include functional assessment

of work-related activities

22


Disability Income Claims Veterans Affairs disability outpatient

clinic claims Processing of claims is usually long and

complicated Consider billing VA monthly to avoid

payment delays Follow instructions on patient’s ID card

closely

23


Disability Income Claims State disability claims

Residents of states with disability benefits must obtain claim forms from nearest state filing office

Physician must substantiate disability for claim to be processed

Additional forms/filings may be required if disability is prolonged

24


Questions?

25

Chapter 16 Disability Income Insurance and Disability Benefit Programs

Documents

Transcript of Chapter 16 Disability Income Insurance and Disability Benefit Programs