N.J. Admin. Code § 17:7-18.5

Current through Register Vol. 57, No. 1, January 6, 2025

Section 17:7-18.5 - Definition of total disability

(a) The participant will be considered totally disabled if he or she is unable to perform each duty of his or her occupation and is under the regular care of a physician. After the 12 months following the commencement of such disability benefit payments, he or she must be unable to engage in any gainful occupation for which he or she is reasonably fitted by education, training, or experience. In any event, total disability is not considered to exist if he or she is gainfully employed. However, following an agreement with the insurance company and the policyholder, the participant can continue to receive disability benefits for a limited time while performing some type of work. During the period of rehabilitation the monthly benefit will be the regular payment less 80 percent of the participant's earnings from such rehabilitative position.

(b) For purposes of this section, a participant shall be deemed to be in service and covered by the disability benefit insurance provisions for a period of no more than six months while on official leave of absence without pay if satisfactory evidence is presented to the Division that such leave of absence without pay is due to illness and that the member was not actively engaged in any gainful occupation during such period of leave of absence without pay.

(c) Disability benefit insurance provisions of the group policy or policies shall not cover disability resulting from or contributed to by pregnancy, act of war, intentionally self-inflicted injury, or attempted suicide whether or not sane. For purposes of such disability insurance, the participant will not be considered to be disabled while he or she is imprisoned or while outside the United States, its territories, or possessions.

(d) If the participant has recovered from the disability for which he or she had received benefits and again becomes totally disabled while insured, the later disability will be regarded as a continuation of the prior one unless the participant has returned to full-time covered employment for at least six months. However, if the later absence is due to an unrelated cause and the participant had returned to full-time work, it will be considered a new disability. The disability benefit insurance cannot be converted to an individual policy.

(e) No person shall be covered by the disability benefit provision of the group policy or policies except upon the completion of one year of full-time continuous employment in a position eligible for participation in the Alternate Benefit Program.

N.J. Admin. Code § 17:7-18.5

Recodified from 17:7-18.447 N.J.R. 905(b), effective 5/4/2015.