In last month’s post, we discussed how most long-term disability (“LTD”) policies contain conditions and exclusions that can negatively impact your ability to make a claim or result in the denial of your claim due to a technicality. This month, experienced Boston long-term disability attorney, Jonathan M. Feigenbaum, delves into the post-eligibility terms that will determine whether your condition qualifies as a disability, as well as some terms that may limit the duration of benefits you may be entitled to receive.

Disability/Disabled

Generally, in order to be entitled to long-term disability benefits, you must be unable to perform the material/substantial duties of your “own occupation” or, in some cases “any occupation,” due to injury or illness.  (Note, however, that some policies are specifically directed toward providing coverage only for disabilities caused by accidents.  Further, most LTD policies limit coverage to non-occupational conditions because workers’ compensation will usually provide income protection for occupational injuries and illnesses.)

Own Occupation

It is common for a group LTD policy to define disability differently and more broadly for the initial period (typically two years) following the onset of the disability than for the remainder of the disability.   This broader definition is referred to as an “own occupation” provision. For example, if your particular job involves physical activities, such as lifting, then during the “own occupation” period, you may qualify as totally disabled even though you may be able to perform another job that does not require lifting.

Practically speaking, if your LTD policy contains an “own occupation” provision, then the two most critical elements of filing your disability claim are (1) exact documentation of the material and substantial duties of your occupation; and (2) the medical substantiation that your treating physician will be asked to compile as evidence of your disability.  In both of these areas, particularly during this early phase of the benefit period, it is critical that your application for benefits include sufficient information about your particular job duties and your limitations.  Otherwise, the insurance carrier may simply refer to a general “job description” provided by your employer (which may be very different than your actual duties) or may even refer to a generic “Dictionary of Occupational Titles” definition which, again, may not match up at all with your actual duties and responsibilities. Unfortunately, claim denials based on occupation misclassifications are common.  A savvy Boston long-term disability attorney can help you avoid this frustrating and time-consuming pitfall.

Any Occupation

After the initial “own occupation” period, a group LTD policy will frequently apply a new definition of disability to determine if you may continue to receive disability benefits.  This is referred to as the “any occupation” definition.  The difference between “own occupation” and “any occupation” may not be as dramatic as you would think. Even the “any occupation” definition will typically refer to your education, background and, more importantly, your earnings history in order to determine if you continue to be “disabled.” Just because you may be physically able to perform the duties of a particular job, if that job would not provide you with a level of income that is within a particular “ball park” of what you were earning before becoming disabled (typically, at least 60%), you may still qualify as disabled from performing “any occupation.”  Furthermore, in order to be able to perform “any occupation,” you must have some “reasonable” ability to actually secure the position. Criteria such as the local job market may play a role in this determination and should be presented for consideration.

As you may expect, insurance carriers frequently deny future benefits following the “own occupation” phase of the benefit period.  A thorough understanding of the terms and definitions of your particular policy, as well as an appreciation for how the carrier will apply these provisions is essential to protect yourself from becoming one of these statistics.

Partial Disability

A “partial disability” provision in your LTD policy will generally provide you with a certain percentage of the benefits that you would receive if you were totally disabled if you are able to earn a certain percentage of the income that you were receiving prior to becoming disabled. Below is an example of a partial disability provision:

Partial Disability: If you have met this definition of disability and have satisfied the elimination period, you can return to work on a part-time basis and still receive a partial benefit, provided your earnings are at least 20% less per month than your pre-disability earnings due to that same injury or illness.

Some LTD policies provide partial disability benefits only for a limited duration. As you may be considering your return to work options, it is important to review the partial disability provision of your policy.  It is common to assume that, if you can return to work in any capacity, then your LTD benefits will be exhausted.  With a partial disability provision, that is not necessarily the case.

Filing a claim for partial disability benefits can require additional details that demonstrate the relationship between your continued limitations and restrictions and the portion of your prior job that is affected by those limitations. Likewise, there may be an indirect impact to your prior earnings potential that should be documented for the insurance carrier.

Contact Us

The terms, provisions and processes for LTD claims are not necessarily straightforward or logical. In order to avoid unnecessary delay, or worse yet, a claim denial, it is important that you secure a copy of your actual policy or Summary Plan Description and engage an experienced Boston long-term disability attorney to assist you with filing your initial claim. Call us today, at 866-396-9722, to schedule your free initial consultation.