Business Brief

In the October edition of Business Brief, we covered the PPS Permanent Incapacity (PI) benefit that forms part of the PPS Sickness and Permanent Incapacity benefit.

After a member has claimed 728 days under the Sickness benefit for the same or related sickness, injury or illness, if the member is still unable to attend to their usual professional duties, they will be assessed for the Permanent Incapacity benefit. Members deemed permanently incapacitated will be granted a partial or total PI award. PPS will consider the member for either partially (20% or 60%) or totally incapacitated (100%) based on the medical information and situation of a member. During weekly meetings, the PPS Medical Officer Committee (MOC) considers partial and total PI claims. PPS will pay a member either the partial or total PI benefit if they are permanently totally or partially unable to attend to their usual professional duties. Even with adaptations to work methods/duties or if realignment of professional duties within their specific profession is not feasible for their condition, age, experience and knowledge.

How does PPS determine a partial or total PI claim?

Step 1: VALID 728-DAY SICKNESS CLAIM

The Sickness benefit supports a member for up to two years (728 days) to recover fully from the sickness or injury, to adjust their usual professional duties within their profession or change their work methods due to the impact of the sickness or injury. The 728 days can be continuous or accumulated over several years until a total claim of 728 days for the same, consequential or related sickness or injury is reached.

Step 2: DUTIES PERFORMED BEFORE ONSET OF THE CLAIM

A member’s duties performed before an illness or injury are essential during the PI assessment process. Daily occupational activities can, for example, include driving, standing, walking on even or uneven terrain, bending/stooping, use of both hands, fine coordination, sitting/doing administrative work, lifting objects weighing between 10kg and 20kg or lifting objects weighing more than 20kg.

At PPS, we know that members do not do the same work or have the same daily duties even though they work in the same industry. We look at each member individually and consider their specific occupation and duties.

Example: we have three plastic surgeons:

Although the three doctors are plastic surgeons, their daily duties differ.

Step 3: DETERMINE MENTAL AND DECISION-MAKING SKILLS

During this step, PPS determines if a member’s ability to apply their mental and decision-making skills required for their duties has been affected by the illness or injury.

Example: If a member sustains a brain injury that affects their cognition and prevents them from performing their daily duties, PPS will award a member a 100% PI award.

Step 4: DETERMINE PHYSICAL, COGNITIVE, FUNCTIONAL, AND VOCATIONAL ABILITIES

Take Dr Y as an example. Dr Y needs both his legs and hands to stand and perform surgery. If Dr Y loses one of his limbs, he will not be able to perform the central part of the daily duties of his occupation.

PPS looks at a member’s physical, cognitive, functional and vocational abilities and determines if the illness or injury has limited them in performing their usual professional duties.

Step 5: DETERMINE IF 80% OR MORE OF DAILY DUTIES CAN BE DONE

When a member can perform 80% or more of their daily duties with no or minor adaptations, e.g., desk set-up, adaptive methods, i.e., time management techniques, etc., PPS will not award a member a PI benefit.

Step 6: IF STILL ABLE TO DO 80% OR MORE OF DIALY DUTIES, PI STOPS

If a member has been awarded a PI benefit and their condition improves and they are again able to perform 80% or more of their usual professional duties, the member’s benefit will be reviewed and will stop. Members must inform PPS if their health/condition improves or deteriorates so that a review can be done.

Step 7: DETERMINE PI AWARD BY LOOKING AT ABILITY TO REALIGN PROFESSIONAL DUTIES

PPS does consider whether a member can make (and in some instances already made) changes to their workstation, daily duties, work process, etc. In some cases, during the 728 day sickness claim period, our members make adaptations to allow them to continue working in their occupation. PPS then considers how these adaptations enable the member to perform some of their duties still.

Step 8: 20%, 60% OR 100% PI AWARD

A member is granted a 20% PI award if they cannot perform some of their usual duties but can perform most of their usual duties with minimal adaptations (e.g., minor adjustments to working, caseload, work methods, etc.). PPS also considers their knowledge, age and skills and if it is feasible/reasonable for a member to redirect duties during the sickness claim period.

A member is granted a 60% PI award if the condition renders them unable to perform at least 50% of their usual duties or if their usual or realigned duties can only be performed with significant ergonomic adjustments, adaptive devices or methods.

A member is granted a 100% PI award if their impairment is permanent and further improvement is unlikely. The member can, therefore, not perform most of their duties and realignment of duties is not feasible or reasonable given the significance of their condition, age, experience and knowledge.

Step 9: BOOSTER? YES, NON-REVIEWABLE 100% AWARD

Once a PI award has been made, the PI Booster will automatically convert the award to a non-reviewable 100% award, provided the member was granted a 20% or higher PI award.

PPS may also, from time to time, review PI awards. Members will receive a letter informing them when the review will be conducted and will detail what information will be required for the review. In most instances, the planned review is communicated when the award is made and may be within six months to a year from the date of award (depending on each member and the relevant circumstances, a review can happen earlier than six months after the award). The information required for a review may be an up-to-date report from the treating doctor, an occupational and quality of life questionnaire and, where indicated, an independent evaluation.

Meet John* (63), a pharmacist who claimed for lumbar and other intervertebral disc disorder with radiculopathy. After PPS assessed John’s PI claim, he was awarded a 100% reviewable PI claim. In May 2022, PPS reviewed John’s PI award by assessing the newly completed occupational and quality of life questionnaire and an updated report from John’s treating doctor. Based on all the medical information available, MOC decided to keep John on a 100% PI award. 

Meet Kim* (34), an auditor diagnosed with antiphospholipid syndrome with non-thrombotic manifestations of antiphospholipid syndrome. After Kim claimed the 728 days under the Sickness benefit, PPS assessed Kim for PI. She was awarded a total 100% PI award.

PPS will also not review her PI claim because she has the PI Booster benefit. PPS will be paying Kim the PI cover amount she insured with us until she turns 65. She will also continue to share in PPS profits declared every year**.

Kim and John’s PI payments will grow yearly with the PPS Annual Declared Benefit Adjustment. 

By Monique Drotsky, Technical Marketing Specialist

* The names used are fictitious; however, they reflect real-life claims received by PPS. All valid claims are assessed individually and paid in line with the product rules.
** Members holding qualifying products share in the profit or loss of PPS and past performance is not necessarily indicative of future performance.
PPS is a licensed insurer conducting life insurance business, a licensed controlling company and an authorised FSP.