EX-99.(D).IV 5 app10035493x1_ex99div.htm FORM OF DISABILITY BENEFIT RIDER

Item 30. Exhibit (d) iv.

Disability Benefit Rider


This rider provides benefits if the Insured becomes totally disabled. We discuss this rider, and the rules that apply to it, in the provisions that follow.

Rider Part Of The Policy

This rider is made a part of this policy as of its Rider Issue Date, in return for the application for this rider and the payment of monthly rider charges. The Rider Issue Date is shown in the Policy Specifications for this rider. Monthly rider charges are discussed later in this rider. All the provisions of this policy apply to this rider, except for those that are inconsistent with this rider. This rider is in force from its Rider Issue Date or, if later, the date the first premium under this policy is paid.

Rider Benefits

This rider provides two types of benefits if the Insured becomes totally disabled. They are described as follows.

1.    We will credit an amount of money to the account value of this policy on specific Monthly Charge Dates. We call this the Specified Benefit Amount; it is described later in this rider. It will be treated as a net premium subject to the terms of the policy.
2.    We will waive – that is, not deduct from the account value of the policy – the monthly charges for the policy due on specific Monthly Charge Dates.

These benefits will be provided after the Insured has been totally disabled for four months and all conditions of this rider are met. Subject to the other provisions of this  rider, the Monthly Charge Dates for which each type of benefit will be provided are:

  •      Any Monthly Charge Date (except the Rider Date) during the first four months of the Insured's total disability; and
  •      Any Monthly Charge Date thereafter during the continuance of total disability but before the Insured's Attained Age reaches 65; and
  •      For the waiver of monthly charges type of benefit, all Monthly Charge Dates thereafter if total disability begins before Attained Age 60 and continues to Attained Age 65.

For any of these Monthly Charge Dates that have already passed at the time a claim is approved, the account value of this policy will be adjusted to reflect provision of these benefits. We will not refund any premiums paid during the time we are approving a claim. The Rider Date is shown in the Policy Specifications for this rider.

If there is any policy debt while the Insured is totally disabled, the allowance of benefits under this rider does not guarantee that this policy will continue in force.

When Benefits End

The benefits under this rider will end when any of the following occurs:

  •     The Insured is no longer totally disabled; or
  •     Satisfactory proof of continued total disability is not given to us as required; or
  •     The Insured refuses or fails to have an examination we require; or
  •     For the Specified Monthly Amount, the day before the Insured's Attained Age becomes 65; and
  •     For waiver of monthly charges, the day before the Insured's Attained Age becomes 65 if total disability began when the Insured's Attained Age was 60 or older.

 

 

Specified Benefit Amount

For any Monthly Charge Date while the Insured is totally disabled, the Specified Benefit Amount is equal to:

  •     The Monthly Specified Benefit Payment Per Thousand Of Face Amount; multiplied by
  •     The Face Amount of this policy when total disability began; and divided by
  •     1,000.


The Monthly Specified Benefit Payment Per Thousand Of Face Amount is shown in the Policy Specifications for this rider.


Exclusions

This rider does not provide any benefit for:

  • Any Monthly Charge Date before the Insured's Attained Age 5;
  • Total disability directly caused by any willfully and intentionally self-inflicted injury; or
  • Total disability caused by war while the Insured is in the military forces of any country at war or in any civilian noncombatant unit serving with those forces. "War" includes undeclared war and any act of war. "Country" includes any international organization or group of countries.

Limitation On Right To Increase Face Amount

Each increase in the Face Amount of the policy may cause an increase in the benefit amount for this rider. In certain cases, however, benefits under this rider cannot be increased. In those cases, we have the right to refuse an increase in the Face Amount. Those cases are:

  •     The rider benefits after the increase would exceed our published limits for such benefits;
  •     The Insured does not meet our underwriting requirements for the additional rider benefits; and
  •     A higher rating would apply to the additional rider benefits than to the existing benefits.


This limitation does not apply to any increase under the policy not requiring evidence of insurability.

Total Disability

Total disability is the incapacity of the Insured that:

  •     Is caused by sickness or injury; and
  •     Begins while this rider is in force; and
  •     For the first 24 months of any period of total disability, prevents the Insured from performing, for compensation, wage or profit, substantially all the duties of the Insured's occupation; and
  •     After total disability has continued for 24 months, prevents the Insured from engaging, for compensation, wage or profit, in any occupation the Insured is qualified to perform.


For the first 24 months of any period of total disability, the Insured's occupation is the Insured's usual work, employment, business, or profession at the time total disability began. After total disability has continued for 24 months, any occupation the Insured is qualified to perform means any work, employment, business, or profession the Insured is reasonably qualified to do based on  training, or experience. Until the Insured

 

 

reaches an age at which formal education may be legally ended, occupation means attendance at school.

Example:

You are a full-time surgeon. You receive an injury to your hands that prevents you from performing surgery, but you can carry on a general medical practice. For the first 24 months, your occupation is surgeon. After that time, your occupation will be any that you are reasonably qualified to do based on your education, training, or experience. Since you can carry on a general medical practice, we would no longer consider you to be totally disabled.

For some conditions, we consider the Insured to be totally disabled even if the Insured is able to work. These conditions are the total loss of sight of both eyes, or the total loss of use of both hands, or both feet, or one hand and one foot. Any of these will be total disability as long as the loss continues.

Recurrent Disabilities

A period of total disability following an earlier period of total disability that was due to the same, or a related, condition may be considered to be a continuation of the earlier period. This depends on how much time passed from the end of the earlier period to the beginning of the current one. If less than 6 months have passed, we will consider it to be a continuation of the earlier period. If 6 months or more have passed, we will consider it to be a new period of disability.

Example:

You were totally disabled for 10 months because of a severe knee injury. Two weeks after you recover, your knee fails and you are totally disabled again. We consider this to be a continuation of the earlier period of total disability.

Notice Of Claim

Notice of claim means written notice that the Insured is totally disabled and that a claim may be made under this rider. We require that this notice identify the Insured. Notice given by or for the Owner shall be notice of claim.

No benefit will be allowed unless this notice is given to us while the Insured is living. However, if it was not reasonably possible to give us notice of claim while the Insured was living, the delay will not reduce the benefit if notice is given as soon as reasonably possible.

Proof Of Claim

Before any benefit is allowed, proof of claim must be given to us at our Administrative Office. Proof may be given by or for the Owner. Proof of claim means written proof, satisfactory to us, that:
  •     The Insured is totally disabled; and
  •     Total disability began while this rider was in force; and
  •     Total disability began before the Insured's Attained Age 65; and
  •     Total disability has continued for four months.

We have forms that are to be used to make a claim. They will be sent promptly upon request. As part of the proof of claim, we have the right to require an examination of the Insured at our expense by a physician chosen by us.

 

 

When Proof Of Claim Must Be Furnished

Proof of claim must be received at our Administrative Office within one year after the notice of claim was given to us. However, if it was not reasonably possible to give us proof of claim on time, the delay will not reduce the benefit if proof is given as soon as reasonably possible.

Proof Of Continued Disability

During the first two years after proof of claim is received, we may require satisfactory proof of continued disability at reasonable intervals. After two years, we may require proof not more than once a year. As part of this proof, we have the right to require an examination of the Insured at our expense by a physician chosen by us.

Proof of continued disability will not be required once the Insured has become Attained Age 65 if total disability began before the Insured was Attained Age 60.

Rider Charges

Each month while this rider is in force, the rider charge is the sum of the waiver charge and the specified benefit charge. The waiver charge each month equals the sum of the policy monthly charges for the month, excluding the rider charge for this rider, multiplied by the Waiver Charge Rate for the Insured's Attained Age. The specified benefit charge each month equals the policy Face Amount for that month, divided by 1,000, then multiplied by the Specified Benefit Charge Rate for the Insured's Attained Age. The Waiver Charge Rates and the Specified Benefit Charge Rates are shown in the Policy Specifications for this rider.

Example:

The sum of the policy monthly charges for the month is $200. The Waiver Charge Rate for the Attained Age of the Insured is 0.075. The waiver charge for that month is $15.00 ($200 multiplied by 0.075).

The Policy Face Amount for the month is $500,000. The Specified Benefit Charge Rate for the Insured's Attained Age is 0.008384. The specified benefit charge for that month is $4.19 ($500,000 divided by 1,000; then multiplied by 0.008384).

The rider charge for that month is $19.19 ($15.00 plus $4.19).

Rider Premium Expense Factor

The Rider Premium Expense Factor is shown in the Policy Specifications for this rider. It is used to determine the premium expense charge and the net premium. See the Net Premium provision in Part 2 of the policy.

While this rider is in force, premium payments made on this policy will be allocated to each segment of the policy Face Amount and to any benefit rider this policy has, including this rider. This allocation will be made on a pro rata basis using the Premium Expense Factor for each segment of the policy Face Amount, the Rider Premium Expense Factor for each rider, and the Rider Premium Expense Factors for any increases in each rider.

Contestability

We can bring legal action to contest the validity of this rider for any material misrepresentation of a fact made in the application for this rider. However, we cannot, in the absence of fraud, contest the validity of this rider after it has been in force during the lifetime of the Insured for two years after its Rider Issue Date. The Rider Issue Date is shown in the Policy Specifications for this rider.

 

 

Termination Of This Rider

While monthly charges for this rider are being deducted from the account value of this policy, this rider will continue in force to, but not including, the Policy Anniversary Date on which the Insured's Attained Age becomes 65. However, any benefits under this rider for which the Insured qualified before termination may be claimed after termination as specified in the Notice Of Claim provision.

Cancellation Of This Rider

This rider may be cancelled by the Owner's written request. Such cancellation will take effect on the policy Monthly Charge Date that is on, or precedes, the date we receive the written request.

MASSACHUSETTS MUTUAL LIFE INSURANCE COMPANY

  /s/ R.J. O'Connell   /s/ Ann F. Lomeli  
  PRESIDENT   SECRETARY  

 

                                                                                                                                                        

     POLICY SPECIFICATIONS
DISABILITY BENEFIT RIDER

POLICY NUMBER:
123456789
INSURED:
JOHN A. DOE
RIDER ISSUE AGE AND GENDER:
35    MALE
RIDER DATE:
JANUARY 1, 2001
RIDER ISSUE DATE:
JANUARY 1, 2001
DISABILITY BENEFIT CLASS:
PREFERRED NONTOBACCO
RIDER PREMIUM EXPENSE FACTOR:
295.00

 

MONTHLY RIDER CHARGE RATES
                       
PART ONE - WAIVER CHARGE RATES
                       
   
WAIVER
     
WAIVER
     
WAIVER
 
ATTAINED
 
CHARGE
 
ATTAINED
 
CHARGE
 
ATTAINED
 
CHARGE
 
   AGE
 
RATE
 
AGE
 
RATE
 
AGE
 
RATE
 
                       
      35
  0.072   45   0.096   55   0.228  
      36
  0.072   46   0.108   56   0.240  
      37
  0.072   47   0.120   57   0.240  
      38
  0.072   48   0.132   58   0.240  
      39
  0.072   49   0.144   59   0.189  
      40
  0.072   50   0.156   60   0.168  
      41
  0.072   51   0.168   61   0.108  
      42
  0.084   52   0.180   62   0.060  
      43
  0.084   53   0.204   63   0.024  
      44
  0.096   54   0.216   64   0.012  
                       
PART TWO - SPECIFIED BENEFIT CHARGE RATES
                       
   
SPECIFIED
     
SPECIFIED
     
SPECIFIED
 
   
BENEFIT
     
BENEFIT
     
BENEFIT
 
ATTAINED
 
CHARGE
 
ATTAINED
 
CHARGE
 
ATTAINED
 
CHARGE
 
   AGE
 
RATE
 
AGE
 
RATE
 
AGE
 
RATE
 
                       
      35
  0.007336   45   0.009956   55   0.016768  
      36
  0.007336   46   0.010480   56   0.017292  
      37
  0.007336   47   0.011004   57   0.017816  
      38
  0.007860   48   0.012052   58   0.018864  
      39
  0.007860   49   0.012576   59   0.019388  
      40
  0.008384   50   0.013100   60   0.020436  
      41
  0.008384   51   0.013624   61   0.020960  
      42
  0.008384   52   0.014672   62   0.022008  
      43
  0.008908   53   0.015196   63   0.022008  
      44
  0.009432   54   0.015720   64   0.022008  

MONTHLY SPECIFIED BENEFIT PAYMENT PER THOUSAND OF FACE AMOUNT: $0.44