Long Term Care Glossary

Non cancelable/Guaranteed Renewable to Age 65: Until you reach age 65, your policy cannot be canceled, premiums cannot be increased, and restrictions cannot be added, as long as you continue paying premiums as due.

Conditionally Renewable for Life: You may renew this policy on each policy anniversary after age 65 for life if you are actively working at least 30 hours each week, you are not receiving a benefit under this policy or any attached rider, and the policy is in force with no premiums in default. When renewing your policy, you will need to submit documentation of your current income and pay the premium due for your age at that time.

Base Monthly Benefit: Base Monthly Benefit is payable for each month you are totally disabled, under the terms of the policy, due to accident or sickness. Benefits begin after you satisfy the elimination period. Benefits continue as long as you remain totally disabled or to the end of the benefit period you select, if sooner.

Own Occupation for the Length of the benefit period (OO): Total Disability or Totally Disabled means that, solely due to sickness or injury, you are not able to perform the material and substantial duties of your occupation. Your occupation means the occupation or occupations that you were engaged in, based on the duties you were performing for wage or profit, at the time disability began.

If you are a physician or dentist and have limited your duties to the performance of the usual and customary functions of a specific, professionally recognized medical or dental specialty, that specialty is considered your occupation.

Waiving Physician’s Care: While you are disabled, you must be under the regular care and treatment of a physician appropriate for the condition causing disability. This requirement may be waived, if, in the opinion of that physician, continued medical treatment will not improve your condition.

Successive Periods of Disability: Successive periods of disability will be considered as one period if:
(a) they are caused by the same or related conditions,
(b) they are separated by less than 365 days, and
(c) each begins while the policy is in force. The elimination period and benefit period will not restart.

Exceptions and Limitations: Benefits will not be paid: (a) for a disability caused or contributed by war, declared or undeclared, or any act or incident of war, or as a result of military service when scheduled active duty is more than three months, (b) for a disability resulting from an intentionally self-inflicted injury, (c) during any period you are incarcerated, (d) except as direct result of sickness or injury, if you are prevented from engaging in your occupation as a result of suspension, revocation, or surrender of your professional license or certification, or (e) for more than 24 months during the lifetime of the policy for total disability caused by a mental/nervous disorder and/or drug or alcohol abuse.

 

Base Policy Definitions

Non disabling Injury Benefit: If you suffer an injury requiring medical treatment prescribed by a physician or the repair to natural teeth prescribed by a dentist, your carrier will pay the expense of such treatment, not to exceed the lesser of 50% of the base benefit or $3,000. (Not available for Colorado, Connecticut, Maryland or Massachusetts.)

COBRA Premium Benefit: If, you become unemployed due to a disability and, as a result, you are paying COBRA medical coverage premiums, you will be reimbursed for those premiums up to $1,000 a month, beginning with the first premium due after you satisfy the elimination period of this policy but not to exceed 18 months. Reimbursement is also available if continuing your employer-group medical plan under the provisions of a state continuation plan. Carriers will not pay more than 100% of the COBRA premium expense incurred monthly.

Survivor Benefit: Should you die after satisfying the elimination period and while monthly disability benefits are being paid under the policy, an additional three months of Base Monthly Benefit will be paid to your designated beneficiary, if any, otherwise to your estate.

Good Health Benefit: For every consecutive policy year you complete without receiving any benefits under the policy, the elimination period is reduced by two days. In no case will the elimination period be reduced to less than 30 days.

Presumptive Total Disability: You will be considered totally disabled if you sustain the complete loss of hearing in both ears, sight in both eyes, speech, or the use of any two limbs. The elimination (waiting) period will be waived, and benefits will be payable for as long as the presumptive disability continues, even if you are working in an occupation. The loss does not need to be permanent or irrecoverable.

Surgical Transplant Benefit: After your policy has been in force for 6 months, if a part of your body is transplanted into another person’s body and as a result you become totally disabled, we will pay benefits as if the disability was due to a sickness, except that we will waive the elimination period.

Cosmetic Surgery Benefit: If a total disability results from cosmetic surgery to correct a disfigurement or to improve your appearance, we will consider you Totally Disabled due to sickness, provided the cosmetic surgery occurs more than six months after the issue date of the policy.

Rehabilitation: You can participate in an occupational rehabilitation program without being considered “recovered” from your disability. Moreover, if we approve the program, we will pay for the reasonable expense of the program, subject to our mutual agreement in writing.

Waiver of Premium: After 90 days and once a claim is approved, we will begin waiving premiums for as long as you are disabled – even beyond the benefit period. We will refund the premiums paid during the elimination period.

Capital Sum Benefit: A one-time, lump sum payment if disability is due to injury and you have a complete, irrecoverable and irreparable loss of 1) use of one hand or one foot; or 2) the entire sight in one eye.

 

Definition of Possible Riders

Enhanced Residual Disability Rider: We will pay you a residual benefit while you are residually disabled if you suffer a loss of at least 15% of your net earned income, and you are able to perform one or more, but not all, of the material and substantial duties of your occupation or you are unable to engage in your occupation for more than 80% of the time as was usual prior to the start of your disability.

Recovery Benefit: In the month immediately following a period for which disability benefits have been paid, upon recovery and return to your occupation on a full-time basis, a residual benefit will be paid if you maintain a loss of, at least, 15% of your net earned income and that loss is a direct result of your previous disability.

Cost of Living Adjustment Rider: As long as you remain disabled, the Base Monthly Benefit will be increased by the lesser of 6% compounded annually or the change in the Consumer Price Index (CPI-U), on each anniversary of the date of disability. Benefits will not be increased by this rider after age 65 but will remain at the same level applicable at age 65 until benefits cease. You have a qualified right to purchase the increase amount under this rider upon your recovery and return to your occupation on a full-time basis.

Catastrophic Disability Rider: Following the elimination period for this rider, carriers will pay the Catastrophic Benefit amount for each month that you are catastrophically disabled due to injury or sickness.

Ameritas Definition: Catastrophically disabled means you are unable to perform two or more activities of daily living without stand-by assistance; or you require substantial supervision due to severe cognitive impairment. Activities of daily living are: dressing, toileting, transferring, continence, eating, and bathing. Benefits continue as long as you remain catastrophically disabled or to the end of the Catastrophic Maximum Benefit Period, if sooner.

Met Life Definition: Due to injury or sickness, you have complete, irrecoverable and irreparable loss of 1) the use of both hands, or both feet, or one hand and one foot; sight in both eyes; speech or hearing in both ears; or 2)are totally disabled due to Alzheimer’s disease or other irreversible form of senility or dementia; or 3) are totally disabled and have Aphasia; Hemiparesis; Paraplegia or Quadriplegia.

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