Language map

Income protection claims mix four different vocabularies. Mixing them up is one of the main reasons valid claims fail. Use this map to see which word belongs where — and what insurers actually test.

What people say What doctors write What work needs What policies test

The four-step ladder

Claims move upward — policy only pays when you can connect step 4 back to steps 1–3.

What happened Sickness · Illness · Injury · Condition What words do you naturally use to describe it?

What medicine records Diagnosis · Symptom · Impairment · Prognosis What has a doctor documented?

What work requires Functional capacity · Material duties · Limitations Which duties can you no longer perform, and why?

What the policy pays on Incapacity · Disability · Own occupation · Partial/total Which policy test applies at your claim stage?

Often confused — side by side

Tap a row mentally: left word is not the same as right.

Diagnosis ≠ Disability

Diagnosis — Medical label — what the condition is called

Disability — Policy outcome — whether you meet the insured work test

A serious diagnosis does not automatically win; a modest diagnosis can still support disability if duties are impossible.

Claim tip: Always pair each diagnosis with duty-impact evidence.

Drill down →

Illness ≠ Incapacity

Illness — Everyday health problem language

Incapacity — Policy trigger word for when benefits logic starts

You can be ill before policy incapacity begins — dates matter.

Claim tip: Build a date ladder: symptom onset → cannot perform duties → DOA → first notice.

Drill down →

Total disability ≠ Partial disability

Total disability — Usually: cannot perform the insured occupation (or no work/earnings from it)

Partial disability — Some work continues; benefit often a proportion of the total benefit from an earnings or hours drop

These are policy doors, not medical grades. A serious diagnosis can sit in residual if two days of work continue. A driver who cannot drive can be total under own occupation even if a desk job exists.

Claim tip: List duties that stopped and duties that continue. Capture pre-disability versus current earnings and hours. Do not volunteer light duties without reading the residual clause.

Drill down →

Pre-existing condition ≠ Date of Absence

Pre-existing condition — Exclusion clocks and causation — look-back, first-year window, what caused disablement

Date of Absence — When policy incapacity / duties-stopped is deemed to have begun

A historic diagnosis is not the disablement date. Pulling Date of Absence back into the first twelve months can wrongly switch a pre-existing exclusion on; leaving it on the day duties actually stopped can switch the same clause off (NFO CR356).

Claim tip: Build both clocks: look-back notes versus the day material duties stopped. Do not let a later diagnosis or an earlier ache move DOA without evidence.

Drill down →

Injury ≠ Illness

Injury — Event-based harm

Illness — Disease, disorder, or deterioration — often no single accident

Policies may treat causation, exclusions, and evidence differently.

Claim tip: Document the story: sudden event vs gradual onset.

Drill down →

Symptom ≠ Functional limitation

Symptom — What you feel

Functional limitation — What you cannot do at work because of it

Insurers need the second. Symptoms are the raw material.

Claim tip: Use format: "Because of [symptom], I cannot [duty]."

Drill down →

Capacity (unaided) ≠ Performance (with treatment)

Capacity (unaided) — WHO-ICF: what you can do without aids in a standard setting

Performance (with treatment) — WHO-ICF: what you actually do with treatment, aids, and environment

Income-protection policies usually assess treated performance. Discrimination statutes often look at the unmitigated baseline. Mixing those axes is the mitigated-state trap.

Claim tip: Write both: function without current treatment, and function on the treatment you actually take — including side-effects.

Drill down →

Functional capacity ≠ Activities of daily living

Functional capacity — Work-duty performance

Activities of daily living — Home/self-care tasks

IP own-occupation claims usually need work-function proof, not only ADL.

Claim tip: Confirm which test your policy clause actually uses.

Drill down →

Impairment ≠ Disability (policy)

Impairment — Clinical reduction in function

Disability (policy) — Contractual benefit entitlement test

Medical ratings and policy tests use different scales.

Claim tip: Translate impairment findings into material-duty language.

Drill down →

Sickness ≠ Incapacity

Sickness — Colloquial absence from work

Incapacity — Defined policy concept with date and test consequences

HR may accept sickness while insurer disputes incapacity under policy.

Claim tip: Do not assume employer sick-note acceptance equals insurer incapacity acceptance.

Drill down →

Job title ≠ Material duties

Job title — Label on contract or email signature

Material duties — Tasks that actually define whether you can work

Senior titles often hide cognitive, client, and safety demands.

Claim tip: Describe duties from reality, not business card.

Drill down →

What people say

Everyday words — loose, emotional, not policy tests

🤒

Sickness

Feeling unwell or off work for health reasons — often short and vague.

This is

A casual way to say you cannot work today
May appear on sick notes or HR forms

This is not

A policy disability test
Proof that benefits are payable

Policy angle — Policies rarely define 'sickness' on its own. Look for incapacity, disability, or inability to perform duties.

Evidence: Sick note, HR absence record Often mixed with: Illness, Incapacity

"I have been off sick for two weeks."

🩺

Illness

A health problem — usually disease or disorder, mental or physical, often ongoing.

This is

Broader than a single sick day
Covers depression, cancer, chronic pain, autoimmune disease, etc.

This is not

Automatically the same as 'injury'
The same as policy 'disability'

Policy angle — People say 'illness'; policies say 'incapacity' or 'disability'. The policy tests work impact, not the word illness.

Evidence: Diagnosis, treatment records, specialist letters Often mixed with: Condition, Diagnosis, Disability

"My illness started after a stressful project period."

🩹

Injury

Harm from a specific event — accident, fall, surgery, assault, sport trauma.

This is

Usually has a when/where/how story
Often documented in hospital or casualty records

This is not

Every medical problem (many illnesses have no single injury event)
Automatically excluded or covered — check policy

Policy angle — Some policies split accident vs illness benefits or apply conduct exclusions to self-inflicted injury. Read exact wording.

Evidence: Hospital report, ICD external-cause codes, employer incident report Often mixed with: Illness, Condition

"Back injury after lifting equipment on site."

📋

Condition

Neutral umbrella for any diagnosed or reported health issue.

This is

Useful when you are unsure of illness vs injury
Common on forms and medical certificates

This is not

A substitute for explaining work impact
A policy-defined claim ground by itself

Policy angle — Insurers may latch onto a condition label (e.g. 'anxiety') without assessing duty impact — that is the diagnosis trap.

Evidence: Medical certificate, specialist report Often mixed with: Diagnosis, Pre-existing condition

A form may say 'pre-existing condition' — that does not automatically defeat post-cover deterioration.

What doctors write

Clinical record language — facts about health, not your job

🏷️

Diagnosis

The medical label a doctor assigns — a name for what they think you have.

This is

ICD-10/11 code, specialist opinion, hospital discharge summary
Starting point for medical chronology

This is not

Proof you cannot work
The insurer's final decision

Policy angle — Strongest trap in IP claims: rejection because 'diagnosis not severe enough' when the real test is occupational function.

Evidence: Consultation notes, specialist report, hospital summary Often mixed with: Disability, Incapacity, Symptom

"Major depressive disorder" on a script is a diagnosis, not a disability finding.

💫

Symptom

What you experience — pain, fatigue, brain fog, panic, nausea, weakness.

This is

Subjective but real
Often what makes duties impossible day to day

This is not

Always visible on tests
Less important than diagnosis — symptoms drive function

Policy angle — Mental illness and pain clauses sometimes demand 'objective' evidence. Functional mapping still links symptoms to duties.

Evidence: Your symptom log, doctor notes, medication side-effect record Often mixed with: Diagnosis, Functional limitation

"Cannot concentrate for more than 20 minutes" is a symptom with direct work impact.

📉

Impairment

Medical loss or reduction of body or mind function — clinical, not occupational.

This is

Used in reports, RFC forms, disability assessments
Can exist without total work absence

This is not

The same as policy disability
Only about job title

Policy angle — Impairment % from a medical board does not automatically equal IP benefit entitlement under own-occupation wording.

Evidence: Functional assessment, specialist impairment rating Often mixed with: Functional limitation, Disability

30% whole-person impairment may still prevent your specific consulting role.

🔭

Prognosis

Doctor's view of likely future course — recovery, stability, or deterioration.

This is

Supports waiting-period and benefit-duration arguments
Needed when insurer expects return to work

This is not

A guarantee of outcome
Optional fluff — it shapes benefit period disputes

Policy angle — Temporary vs permanent disability clauses hinge on prognosis language — capture exact doctor wording.

Evidence: Specialist letter, treating practitioner opinion Often mixed with: Diagnosis, Functional capacity

"Guarded prognosis with episodic relapse" affects return-to-work expectations.

What work needs

The bridge insurers actually care about — can you do the job?

⚙️

Functional capacity

What you can and cannot do in real life — especially material work duties.

This is

Attendance, stamina, cognition, safety, reliability, travel tolerance
The evidence insurers often say is 'missing'

This is not

A diagnosis
Your job title
A generic sick note alone

Policy angle — Own-occupation IP claims live or die here. This is the bridge from medical notes to policy test.

Evidence: Duty-impact statement, OT report, detailed doctor questionnaire Often mixed with: Diagnosis, Disability, Activities of daily living

"Cannot manage client deadlines, supervision, or site travel" = functional, not just medical.

🎯

Material duties

Core tasks that actually matter in your role — not incidental admin.

This is

Client delivery, decision-making, safety oversight, billable hours, error risk
Defined from contract, JD, and reality

This is not

Job title alone
Every minor task in a long HR description

Policy angle — Job-title trap: 'manager' understates cognitive load, client pressure, or travel demands.

Evidence: Job description, performance reviews, your own duty list, employer statement Often mixed with: Occupation, Own occupation

Job title 'Partner' on a letterhead is not sedentary admin if the role needs client-facing pressure.

🚧

Functional limitation

A specific barrier — X symptom stops Y duty, with severity and frequency.

This is

Structured links: fatigue → cannot finish workday; anxiety → cannot present to clients
Feeds doctor questionnaire and claim pack

This is not

Vague 'I feel terrible'
A diagnosis restated without duty link

Policy angle — Build a limitation matrix: limitation → duty affected → medical source → still missing evidence.

Evidence: Symptom log mapped to duties, OT/psych report, employer observation Often mixed with: Symptom, Impairment

"Medication morning sedation prevents 08:00 client meetings three days per week."

🏠

Activities of daily living (ADL)

Basic self-care and home tasks — dressing, bathing, cooking, mobility.

This is

Common in severe disability and lump-sum policy tests
Sometimes used in medical assessments

This is not

The main test for own-occupation income protection
A substitute for work-duty evidence

Policy angle — ADL-focused evidence may not answer whether you can perform your occupation — know which test applies.

Evidence: OT ADL assessment, hospital rehab notes Often mixed with: Functional capacity, Material duties

Can shower independently but still cannot sustain a full consulting day — different tests.

What policies test

Binding claim language — definitions in your policy wording

📜

Disability

Policy-defined inability to meet the insured disability test — not a medical opinion.

This is

Defined in policy wording — own occupation, any occupation, partial, etc.
What the insurer must decide

This is not

Whatever a doctor wrote on a certificate
A universal medical status

Policy angle — Always ask: which test applies now — Initial Period own occupation vs Extended Period any occupation?

Evidence: Policy clause, functional-duty proof, insurer assessment file Often mixed with: Diagnosis, Impairment, Incapacity

Policy may require inability to perform material duties of own occupation for 6+ months.

📅

Cover start

When your group income protection membership or benefit cover began.

This is

Date on policy schedule, member certificate, or HR benefits confirmation
Used for pre-existing condition and eligibility arguments
May differ from employment start date

This is not

The same as symptom onset or Date of Absence
Automatically the day you joined the employer
Proof that a claim must be accepted

Policy angle — Commencement of cover clauses often require you to be actively at work. Insurers use this date for look-back and pre-existing exclusions.

Evidence: Policy schedule, member certificate, HR benefits pack, employer confirmation Often mixed with: Employment start, Symptom onset, Waiting period

Cover from 1 Mar 2022 on schedule — insurer may argue symptoms before that date are pre-existing.

⏳

Waiting period

Deferred or elimination period — continuous absence/incapacity before benefits start.

This is

A fixed period defined in policy wording (days or months)
Measured from Date of Absence or first day of incapacity — check your clause
Requires continuity evidence across the whole period

This is not

The same as symptom onset or your first sick note
Optional — most group IP policies have one
Automatically over because HR accepted absence

Policy angle — Also called deferred period or elimination period. Benefits usually start only after you satisfy this period without recovery gaps that reset the clock.

Evidence: Policy schedule, absence register, medical certificates covering full period, employer statement Often mixed with: Symptom onset, Date of Absence, Sickness, Incapacity

3-month waiting period from DOA — insurer may dispute if you returned to light duties for one week mid-period.

⛔

Incapacity

Unable to work (or meet earnings) as defined by the policy — close cousin to disability.

This is

Common label in SA group income protection policies
Often tied to Date of Absence and waiting period

This is not

Any day you feel too ill to attend
Automatic because HR accepted a sick note

Policy angle — Date of Absence usually marks when incapacity began for benefit purposes — a different date from symptom onset or first sick note.

Evidence: Policy definition, chronology, employer statement, medical records Often mixed with: Sickness, Disability, Date of Absence

Incapacity for policy purposes may start when you cannot perform material duties, not first mild symptoms.

📆

Date of Absence

The date incapacity began for policy purposes — often when material duties stopped, not first symptoms.

This is

Anchor date for waiting period and benefit chronology
Recorded by you, employer, and insurer — may differ between them
Often the day you could no longer perform core occupational duties

This is not

The same as symptom onset or first mild sick day
Automatically the date on your first medical certificate
Chosen by you alone — insurers calculate and may dispute it

Policy angle — DOA disputes are common. Insurers may select an earlier date (pre-existing) or later date (light duties). Build a date ladder with evidence for each rung.

Evidence: Employer absence register, medical certificates, duty-impact statement, insurer claim file Often mixed with: Symptom onset, Incapacity, Waiting period, Cover start

Symptoms from March; stopped client-facing duties 12 June (your DOA); first certificate 14 June.

◐

Total vs partial disability

Two policy doors, not two medical grades: total usually means you cannot perform the insured occupation; partial (residual) means some work continues and earnings or hours have dropped.

This is

A wording choice in the policy — total, partial, residual, or proportionate
Often an earnings or hours formula once some work continues
Still a duty test: residual usually requires that you cannot do one or more material duties
Capable of flipping over time — total in month one, residual on a graded return

This is not

A medical severity score (mild / moderate / severe is not the test)
The same as temporary versus permanent
Automatically total because you have a serious diagnosis
Automatically partial because you answered an email from the sofa

Policy angle — Read the residual / partial clause before you accept a total-disability frame — or before you volunteer light duties. Many Australian and South African IP wordings pay a proportion of the total benefit when current earnings sit below the baseline the formula uses (sometimes with a minimum drop, often 20%). Hours-based formulae exist too. Offsets, the waiting period, and own occupation versus any occupation still apply. This is organisation of the test, not a calculation of your claim.

Evidence: Pre-disability payslips and hours, current payslips and hours, duty list of what stopped versus what continues, employer confirmation of light duties, policy residual clause and definition of pre-disability earnings Often mixed with: Temporary disability, Functional limitation, Own occupation, Material duties, Disability

Reduced from five client days to two, earnings at 40% of the old figure — that is often argued as partial / residual, not as a failed total-disability claim.

🕰️

Pre-existing condition

A policy exclusion with clocks and causation — not ‘anything a doctor ever wrote’. Look-back window, disablement window, and what actually caused duties to stop.

This is

A clause that can exclude disablement caused by a condition known, treated, or symptomatic in a defined period before cover
Often two clocks on South African group wording: look-back (commonly six months) and first twelve months of cover
In Australia, a PDS definition plus Insurance Contracts Act s 47 (awareness) — and a separate non-disclosure remedy
A matter the insurer usually has to prove, with contemporaneous notes, not a later summary

This is not

Every old diagnosis on a script or medical-aid history
Automatically the same as non-disclosure or a retrospective exclusion added at claim stage
Proved by a historic injury years before the look-back (NFO CR403)
Still alive on typical SA group wording if disablement falls after the first twelve months (NFO CR356)

Policy angle — Read the actual exclusion: whose knowledge, which months, whether symptoms without treatment count, and whether disablement must fall inside a first-year window. Separate a stable baseline from a new post-cover event. South African group files often follow NFO CR356 (two limbs) and CR403 (onus and causation). Australian files split PDS wording, s 47 awareness, and ICA s 29 disclosure. This is organisation of the test — not a decision on your claim.

Evidence: Cover start / entry date, look-back medical notes, occupational-health or fitness clearances just before cover, first advice or treatment dates, new-event records, date duties stopped, treating opinion on causation Often mixed with: Diagnosis, Cover start, Date of Absence, Illness, Waiting period

Back injury in 2003, cover in 2016, leg weakness from 2017 — the 2003 label is not the six-month look-back the clause asked for.

👔

Own occupation

Policy test: cannot perform material duties of the job you actually do.

This is

Usually applies in Initial Period
Needs real duty evidence, not generic title

This is not

Any job you could theoretically do
A medical impairment percentage

Policy angle — Extended Period may shift to any/suitable occupation — track when the test changes.

Evidence: Material duties list, functional statement, employer role confirmation Often mixed with: Material duties, Suitable occupation

Cannot perform your actual consulting role even if you could do sedentary admin elsewhere.

Sentrix Digital, Melbourne · ABN 29 203 554 753. Not medical, legal, or financial advice. Organisation and drafting only. Verify with clinicians, schemes, and policy documents. South African complaints: insurer internal review, then the National Financial Ombud (NFO). · info@sentrixdigital.com · +61 (03) 9088 1341 · Admin login

Language map

The four-step ladder

Often confused — side by side

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