Vision of 20/200 or less in the better eye with correcting glasses, or vision better than 20/200 with a visual field contraction to such an extent that the widest diameter of visual field subtends an angular distance no greater than 20 degrees.
Permanent and Total Disability requires careful definition to the community, and to those individuals who qualify for assistance, lest it come to signify assistance to individuals who can do nothing for themselves and who are looked upon, or come to look upon themselves, as no longer effective members of society. It is not the intention of the State Board that the definition presented should be construed so narrowly as to apply only to persons who are helpless or complete invalids, but rather that the definition apply also to those individuals who by reason of the existence of a major permanent impairment are substantially precluded from engaging in a useful occupation, including homemaking.
If the eligibility factor is considered in two parts some of the difficulties in understanding and interpretation may be minimized.
The term “permanent” refers to a physiological, anatomical, mental or emotional impairment verifiable by medical findings. The doctor carries responsibility for providing the agency with information which bears on this part of the eligibility factor.
The impairment must be of major importance and must be a condition not likely to improve or which will continue throughout the lifetime of the individual. The following is suggested as a working principle on this point of “permanence;” any condition which is considered by the medical reviewer as not likely to respond to any known therapeutic procedures shall be deemed to be permanent; furthermore, any condition which is considered as likely to remain static, or to become worse unless certain therapeutic measures are carried out, shall be deemed to be “permanent” so long as treatment is unavailable, inadvisable, or the individual refuses treatment and his refusal is considered reasonable.
“Permanence” does not rule out the possibility of vocation rehabilitation or even recovery from the impairment. Doctors are aware that individuals will sometimes respond favorably to treatment after an unfavorable prognosis or the condition becomes arrested. The discovery of new drugs or other advances in medical treatment is always a potential which may change a “permanent” situation, but pending the actual physical improvement, the classification is proper. It is clear, therefore, that the term “permanent” is defined in a practical manner and not in an absolute sense. Thus, the term need not be used in the same sense of “everlasting,” “unchangeable,” etc., but may be used relatively in the sense of continuing indefinitely, as distinct from “temporary” or “transient.”
The term “total,” like “permanent” is not an absolute term in that it must be considered in reference to the ability of the person, as revealed by the facts in his case, to perform those activities necessary to carrying out specified responsibilities, such as those necessary to employment or homemaking. “Total” involves consideration of factors in addition to those verified through the medical findings, such as age, training, skills and work experience, and the probable functioning of the individual in his particular situation in light of his impairment.
In contrast to “permanent,” “total” involves no time factor, (does not necessarily mean continuing throughout the lifetime of the individual). For clarification, an individual with a medically established major permanent impairment, who is unable to secure employment or be a homemaker as of now because of limitations placed upon his activities as a result of the impairment combined with his age, training, past employment history and other pertinent social facts is “totally” disabled within our definition.
Such persons are likely to remain “totally” disabled unless they develop a new competence in a field of employment, or in homemaking, compatible with their physical or mental limitations, education, age, skills, etc. Once a new competence is developed in homemaking or for a type of employment available in the community, the individual ceases to be “totally” disabled. There need not have been any change in the permanent impairment.
“Substantially precluded” relates to the extent to which an individual's permanent impairment has left him able to engage in those activities necessary to carrying on specified responsibilities, such as those related to employment or homemaking.
If an individual is able to perform such activities well enough and with sufficient regularity to receive regular payments from his own current efforts, or to carry homemaking responsibilities on a continuing basis, he is not considered as precluded from engaging in “useful occupation” and cannot be found to be a permanently and totally disabled individual. However, individuals meeting one of the two criteria given below may be found to be totally disabled, even though they may receive some remuneration through activities which may have some of the characteristics of a “useful occupation.”
Inability to perform the essential activities of daily living—For the person whose impairment is so severe that it results in his being unable to leave his bed, leave his home, get to nourishment or maintain body hygiene without the help of another person, and for whom the assumption would commonly be made that he could not engage in any “useful occupation,” but in fact, through supreme effort he does do some work, the committee will consider all of the following facts:
The extent to which sympathy or compassion enters into the opportunity to engage in remunerative work. In other words, is he able to do something because family, friend, or neighbors help more than is usual, for example, running errands, bringing him materials, “engineering” the job, helping devise and create special tools, creating a market for him based more on sympathy than intrinsic value received, or selling through church or other organizations without charging him the usual commission.
The extent to which the energy input must be discharged by the person is far beyond that which is ordinarily required for that activity, for example, does it take him six or seven hours to do what most workers can do in an hour.
If, through careful consideration of such facts in addition to the full medical and social-economic reports, the committee is satisfied that this individual is doing more than can ordinarily be expected from individuals with impairments of similar severity, and his activity is not substantially gainful, a finding of permanent and total disability may be reached.
For the individual who does not meet the first criterion, full medical and social-economic studies shall be used to determine whether the inability to perform on a predictable basis any job for which he has any competence and which exists in the community. In order to know whether the individual meets this criterion, there must be medical evidence to support a finding that the physical condition is such that attacks of pain, or shortness of breath, or dizziness, or unusual exhaustion, or some other medically demonstrable reaction, occur at irregular intervals and with such intensity that the individual is precluded from engaging in any “useful occupation” on a predictable basis.
Since irregularity and unpredictability prohibit continuous performance, presumable “employment” in the usual sense is precluded for an individual so limited by a permanent impairment. Any earnings or profits from activity which the individual does engage in would normally be considerably less than that associated with a job in the same field of activity.
If, through careful consideration of such facts in addition to the full medical and social-economic reports, the committee is satisfied that this individual is doing as much as is medically possible for him, and his activity is not substantially gainful, a finding of permanent and total disability may be reached.
Consideration of income of individuals found eligible for permanent and total disability under either of the tests given above will be governed by policies on income and resources.
“Substantially gainful”—An individual receiving remuneration for activities as described above in 3a and b, shall be considered as engaging in a substantially gainful activity when his earnings are equivalent to or in excess of his individual need for food, clothing, incidentals and transportation; computed by assistance standards for these items without reference to his living arrangement.
The term “useful occupation” means productive activities which add to the economic wealth, or produce goods or services to which the public attaches a money value. In this context, “useful occupations” demand the time and attention of the doer for the ultimate benefit of others. Under this interpretation certain activities in which invalids or otherwise seriously incapacitated individuals sometimes engage are not “useful occupations” for purposes of this program. These activities include: hobbies, activity which does not provide a bona fide job opportunity, (i.e., if the individual stopped doing it no one would be hired to replace him); occupational therapy, (i.e., motivated activity prescribed by a physician for remedial purposes for the individual, and carried on under his supervision); that part of a rehabilitation program which is officially designated as “training,” and which is carried on under supervision of the rehabilitation agency.
Under this interpretation, individuals may engage in activity which is part of a training program in their own homes, in school, sheltered workshops, factories or other places offering opportunities for such training. The determining factor is not location, but the presence or absence of supervision and of a training objective as well as the economic value of what is produced. Thus, some persons working in sheltered workshops may be found to be engaging in a “useful occupation,” but others will not be so engaged, since their activities are part of a rehabilitation plan and are not currently of economic significance. Remuneration which may be received through activity cannot be classified as a “useful occupation” as here defined, need not necessarily contravene a finding of permanent and total disability. Such earnings must be considered, however, in the determination of the eligibility factor of need, along with total income from all other sources.
Homemaking involves ability to carry home management and decision-making responsibilities and to provide essential services within the home for at least one person in addition to one's self.
Homemaking derives from a social situation that exists around the individual. This role generally is attributed to women, but it would apply also to any person who has assumed and has been carrying out homemaking responsibilities. Disability of any person having homemaking responsibilities for himself, or herself, and at least one other person will be evaluated in terms of that person's ability to carry out a significant portion of activities important to the successful performance of homemaking on a regular or predictable basis.
Activities considered important to the homemaking role are such as shopping for food and supplies, planning and preparing meals, washing and ironing clothes. In nonmodern homes, the ability to carry water, carry fuel, build fires and so forth would also be considered important to the homemaking role. If the homemaker has responsibility for children, additional activities would be essential to the homemaking role such as those involved in lifting and carrying infants, bathing and dressing children, or training and supervising children.