Permanent and total disability is defined as a disability which prevents an individual from engaging in any gainful or useful occupation existing in his community, provided the disability, either physical or mental, is not likely to become worse or remain static without treatment which is either unavailable, inadvisable or reasonably refused by him. The disability must be substantiated by medical findings reported by a licensed physician, reviewed in connection with social data as discussed in the following sections.

In considering permanent and total disability, it is necessary to appraise both total and permanent as factors in determining eligibility. It is not possible to consider them as separate entities, but it is necessary to think of them in conjunction and to weigh them in relation to a given individual's experience, ability and age. In order to clarify these elements, however, it will be helpful to isolate the parts and then consider their integration.

The element of permanence relates to the medically disabling condition. The impairment must be of major importance and not likely to benefit from any treatment possible in the light of current medical knowledge. There is always the possibility of new scientific discovery, and it is recognized too that sometimes individuals who have been given a conscientious but unfavorable prognosis show unexpected improvement. The term, therefore, is used in a relative sense, and includes conditions which in the opinion of the medical consultant will continue throughout the lifetime of the individual.

In addition to this, any condition may be considered permanent for purposes of eligibility which is, in the opinion of the medical consultant, likely to remain static or become worse unless certain treatment is carried out which is either unavailable, inadvisable or refused by the individual on reasonable grounds. Some types of treatment, particularly those which are the result of new methods or scientific advancements, are available only in the larger medical centers. Others may in some situations be inadvisable because of the possibility that no benefit will result or because of the possibility that remaining function may be lost. Even when there is a reasonable probability that benefit will result, the individual may be opposed to the procedure because of genuine personal scruples, religious or otherwise, or reasonable fear of loss of the remaining function.

The element of totality must be related to the particular individual under consideration and what he can be expected to do in view of his training general ability, and aptitude. Some individuals will never be genuinely disabled in spite of the most permanent handicap because of an innate aptitude or ability and will put their remaining powers to constructive use. Others will be totally disabled because they lack this ability and have no training or experience to enable them to utilize their remaining potentialities or because the disability has arrived when they are at an age to make further learning or adjustment impossible. This can be evaluated only from a complete social history which contains information about previous experience and education and gives some idea of general ability.

These two parts shall be considered together for conclusion regarding an individual's classification as permanently and totally disabled. In effect, it must be shown that he is disabled for any occupation within his individual capacity or competence, which is performed in a location accessible to him. Disability must not be confused with unemployment. For example, a person who is able to engage in any gainful or useful occupation of a type existing in his community would not be classified as permanently and totally disabled, but unemployed. However, work which is made available to an individual because of the interest or compassion of interested persons in the community, but which would not ordinarily exist or which the individual would not be able to do in sufficient quantity to maintain himself, will not be considered a gainful occupation. It may serve a useful purpose for him by providing an outlet for interest and energy and may bring some financial return which should be treated as a resource and considered accordingly in budgeting a case.

In any case where there is a probability of benefit from treatment, every effort shall be made to obtain the client's acceptance of this and to make it available to him. This may require discussing with him fears or objections which he has and exploring and canvassing all possible sources for financial assistance in defraying the costs of such treatment. In such an instance, a decision about continuing eligibility will be made after review of all the factors and the basis for refusal in the State Office. If there is a reasonable assurance that the disability can be reduced or removed, that there is no medical contra-indication to the medical treatment and no fundamental reason for the client's objection, continuing eligibility may be denied.