A primer: Social Security Act programs to assist the disabled

This summary is designed for those who are unfamiliar with the many current features of federally sponsored disability and health programs under the Social Security Act, including the Social Security Disability Insurance (DI) program, the Supplemental Security Income (SSI) program, Medicare, and Medicaid. It provides an overview of the provisions and operations of the programs. Several SSA resources were consulted in compiling the material: Social Security Handbook (available at http://www.socialsecurity.gov/ OP_Home/handbook/handbook.html); Annual Statistical Supplement to the Social Security Bulletin, 2005 (available at http://www.socialsecurity.gov/policy/docs/statcomps/supplement/2005); Trends in the Social Security and Supplemental Security Income Disability Programs, by John Kearney and L. Scott Muller (available at http://www.socialsecurity.gov/policy/docs/chartbooks/disability trends); and Disability program sections of the Social Security Online Web pages (available at http://www.socialsecurity.gov/disability). This summary is intended to assist in understanding the features of these federal disability and health programs. The descriptions are intended for explanatory purposes and do not provide guidance in administrative or claimant actions.

[Extent to which a claimant's loss-mitigation and cooperation obligations towards the insurer are enforceable--requirements for an expert medical opinion]

A policyholder claiming an annuity benefit on the grounds that, he is no longer able to pursue his occupation must meet certain obligations vis-à-vis the insurer, e.g. duty to mitigate the loss, duty to cooperate with the insurer. These obligations are often curtailed by the claimants' rights. Physicians and providers of expert medical opinions frequently do not share this opinion. Where medical and legal considerations intermingle and, potentially, conflict, there is great uncertainty as to whether, and to what extent, an insurer may require a claimant to undergo medical treatment. Before deciding on whether or not to grant an annuity, the insurer generally calls in medical experts to assess the policyholder's actual degree of disability and offer an opinion on whether and, if so, by what medical means that disability might be mitigated or remedied. Expert medical opinions are often decisive in such cases. The present article discusses the extent to which a claimant's loss-mitigation and cooperation obligations towards the insurer are enforceable; in this context, a number of court decisions are quoted. In addition, the authors define the requirements that an expert medical opinion must meet.

Optometrists as "acceptable medical sources" to establish a medically determinable impairment. Final rules

We are revising the Social Security and Supplemental Security Income (SSI) disability regulations regarding sources of evidence for establishing a medically determinable impairment under titles II and XVI of the Social Security Act (the Act). The revised regulations expand the situations in which we consider licensed optometrists to be "acceptable medical sources."

[Opinions issued by an expert appointed by a court in civil cases from the point of view of the defendant insurance company]

The paper presents and analyses problems which are encountered by an insurance company in connection with the opinions issued by experts appointed by a court in civil cases and concerning the evaluation of the results of accidents or damages in civil liability insurance. Every year, the group of physicians employed by the Office of Medical Services of Insurance at the PZU Zycie SA and PZU SA, issues opinions for about 3000 appeal and complicated cases from all over Poland. In some of the cases, an individual holding an accident insurance policy or an injured person in the case of civil liability insurance disagrees with the findings of the insurance company and brings the case to a civil court. About 7% of the opinions issued by the Office in 2005 were polemics with court experts, concerning their manner of classifying the results of an accident or an event which resulted in damage to an individual. Among the 200 opinions, there are several important and recurring problems, which are presented in the paper. The main doubts concern: 1. insufficient analysis of the circumstances of an event and drawing hasty conclusions about the cause-and-effect relationship, 2. claiming the certain occurrence of a cause-and-effect relationship, despite substantial doubts, 3. absence of analysis of general conditions of insurance, which in voluntary insurance may contain various exemptions and restrictions, 4. insufficient analysis of medical documentation containing information about some deviations before the event, 5. determining by the experts the degree of permanent loss of health despite the absence of functional impairment revealed in an examination, 6. determining permanent results of an accident based solely on unverifiable subjective complaints, 7. deciding about the percentage of permanent detriment to health in most cases on a slightly higher level than was decided by a physician who took such a decision for the insurance agency.

Genetic testing and the future of disability insurance: thinking about discrimination in the genetic age

This article considers the future of genetic testing and disiblity insurance, and explores the potential for discrimination when using genetic information.

Genetic testing and the future of disability insurance: ethics, law & policy

Predictive genetic testing poses fundamental questions for disability insurance, a crucial resource funding basic needs when disability prevents income from work. This article, from an NIH-funded project, presents the first indepth analysis of the challenging issues: Should disability insurers be permitted to consider genetics and exclude predicted disability? May disabilities with a recognized genetic basis be excluded from coverage as pre-existing conditions? How can we assure that private insurers writing individual and group policies, employers, and public insurers deal competently and appropriately with genetic testing?

Disability income insurance: the private market and the impact of genetic testing

This article discusses the disability insurance industry in order to provide context regarding the potential impact of genetic testing on disability insurance. It describes disability income insurance, exploring both the protection it offers and its main contract provisions. It goes on to describe the private insurance market and the differences between group and individual insurance, and concludes with implications of genetic testing with respect to the private disability insurance market.

Predictive genetic testing: congruence of disability insurers' interests with the public interest

This article argues that, under existing jurisprudence, the disability insurance business will be harmed, not benefited, from broad access to the results of genetic testing identifying people with higher than species-typical genetic propensities for illness.

[Medical certification standards in the evaluation of inability to work]

The authors attempt to address the question whether it is possible to establish medical certification standards that would be helpful in assessing inability to work. The need for developing such relatively uniform certification standards is indicated in the Report of the Supreme Chamber of Control issued in July 2005. Searching for the answer to the question to what degree such standards can be established, the authors briefly present and review the presently enforced "certification standards" and provided several examples from the history of social security and medical certification in Poland. They also discuss the first Polish textbook of medical certification published by Dr. Franciszek Witaszek in 1935. Another "historical example" recalled in the paper is the textbook edited by Professor Karol Szaniewicz (1959) and entitled: "Medical certification for disability and employment". The authors also mention that several years ago, the Central Institute of Occupational Medicine published an "Occupational guide" that might be of help in developing certification standards in cases of inability to work.

Life, health, and disability insurance: understanding the relationships

Communitarian values are stronger in health insurance than in life or disability insurance. This correlates with increased tolerance for insurers' use of genetic information in disability insurance underwriting, which, in turn, is relevant to the scope and content of proposals to regulate such use.

[Can total loss of ability to paid work mean a simultaneous maintenance of ability to paid work at wages exceeding 100%?]

To illustrate and evaluate the efficiency of presently enforced limits of earning for pensioners and the percentage of working pensioners whose earnings are within the limits, the authors compared data from 2001 and 2005 that described declared income from paid work of pensioners with different grades of inability established by the Pita Branch of the Social Insurance Institute (ZUS). It was demonstrated that only 14.75% of all pensioners in the ZUS Pita Branch declared income from paid work, with 96.55% declaring income below 70% of the average national monthly earnings, 2.12%--between 70-130% of the average monthly earnings, and only 1.32% of individuals declaring income over 130% of the average salary. As it follows from the above analysis, the legal limits of allowable income were applicable to 3.34% of all working pensioners only, imposing limits on their earnings. If the number of professionally active pensioners nationwide subject to income restrictions due to earnings in excess of 70% of the average national monthly salary was compared to the total number of pensioners in the ZUS Pita Branch, the percentage of the latter was only 0.51% in 2005.

[Medical certification problems associated with the so-called social pension--the error underlying the notion of such a medical certifying solution]

On October 1, 2003, the Act on social pension of June 27, 2003, came into force. Social pensions are granted to individuals who are of age and totally unable to work due to somatic deficiencies that have occurred mainly before coming of age (18 years of life). The most important element of the new law is the fact that while assessing the right for the benefit it is not important when the complete inability to work occurred, but that it resulted from somatic deficiency which occurred in the period mentioned above. This kind of solution, however, differs greatly from what was included in the former school-pupil's pension, in the family pension, or in the right to earlier retirement pension of employees having children requiring constant care. Although in all the solutions the premise entitling the individual to receive appropriate benefits was and still is the occurrence of disorders causing complete disability to work (the former second group of disability), in all the former legal solutions, the complete inability to work had to occur in the periods determined by an appropriate law or regulation. Yet, in the case of social pension, it is only an enigmatic malfunction of the organism, which is not defined anywhere and in any way, that has to occur in the periods determined by the regulations. It seems that the law on social pension requires urgent modification.

Genetic testing and disability insurance: an alternative opinion

As members of the Working Group on Genetic Testing in Disability Insurance, the authors of this alternative opinion describe their areas of disagreement with some of the conclusions in the paper written by Susan M. Wolf and Jeffrey P. Kahn.