Opinion ID: 620674
Heading Depth: 2
Heading Rank: 2

Heading: Disability definitions in the relevant policies and statute

Text: Jajuga was enrolled in his employer's group life insurance policy. The Group Policy was insured and administered by Prudential and regulated by ERISA. Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1001 et seq. Jajuga was also a participant in a long-term disability (LTD) benefits plan that was self-insured and administered by MBUSA, and he had purchased an individual life insurance policy from Prudential. He apparently paid his Individual Policy premiums until he sought and obtained a waiver of premiums. After he stopped working on May 6, 1997, Jajuga eventually applied to Prudential for a waiver of premiums on both his Individual Policy and his Group Policy. [3] Under the Individual Policy, premiums are waived for two years if the insured cannot, due to sickness or injury, do any of the duties of his or her regular occupation. Thereafter, premiums are waived if he or she cannot, due to sickness or injury, do any gainful work for which he or she is reasonably fitted by education, training, or experience. Similarly, the Group Policy defines total disability for the purpose of that policy's premium waiver clause as follows: Total Disability: You are Totally Disabled when: (1) You are not working at any job for wage or profit; and (2) Due to Sickness, Injury or both, you are not able to perform for wage or profit, the material and substantial duties of any job for which you are reasonably fitted by your education, training or experience. Prudential does not argue any ground for Jajuga's not recovering Group Life coverage and benefits other than its assertion that he was not eligible for a premium waiver because he was not totally disabled. Jajuga also applied for and received disability benefits under Social Security Disability Insurance (SSDI) and under the MBUSA LTD plan. The statute governing SSDI benefits provides for a disability insurance benefit to an individual who satisfies various criteria and is under a disability. 42 U.S.C. § 423(a)(1). The statute defines disability as the inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months. Id. § 423(d)(1)(A). The statute goes on to state that [a]n individual shall be determined to be under a disability only if his physical or mental impairment or impairments are of such severity that he is not only unable to do his previous work but cannot, considering his age, education, and work experience, engage in any other kind of substantial gainful work which exists in the national economy, regardless of whether such work exists in the immediate area in which he lives, or whether a specific job vacancy exists for him, or whether he would be hired if he applied for work. Id. § 423(d)(2)(A). The MBUSA LTD plan treats the receipt of SSDI benefits as evidence of total disability entitling a covered person to LTD benefits. Jajuga received benefits from Social Security under SSDI and from MBUSA under the LTD plan. In addition, Prudential granted Jajuga a waiver of premiums under his Individual Policy, but Prudential denied his claim for a waiver of premiums under the Group Policy.