If you have a long-term disability (LTD) claim, you’ll probably encounter the words “any occupation disability” or “gainful employment” during the claim process. But, what do the terms mean? If I worked as an outside sales representative or a software engineer or a project manager, does this mean that I am no longer disabled if I could work as a greeter at Walmart or a security camera monitor? Is there a special meaning under the Employee Retirement Income Security Act (ERISA). Keep reading.
LTD Policies Vary Dramatically and You Need to Understand Your Plan
While there are some common elements to an LTD policy, the terms vary. Before you apply for long-term disability benefits, you should always review the most up-to-date plan documents. You should especially review your plan’s summary plan description (SPD) and the ERISA plan instrument often referred to as the Certificate. This document should outline:
- How your LTD plan defines “disability”
- The amount and duration of your potential LTD benefits
- Any excluded conditions that the plan does not cover
- The application process and your appeal rights
- Any deadlines or waiting periods that apply to your claim
- Whether your policy definition of disability changes from “own occupation” to “any occupation” after a period of time
When requested in writing, your employer must provide to you the SPD, the certificate of insurance and all other documents under which the ERISA plan operates.
If you’re having a hard time understanding your SPD or other plan documents, contact a lawyer for help. Many LTD documents use highly technical language or opaque language that is not easy to understand. When in doubt, don’t guess or make assumptions about its requirements. Instead, request an appointment with an ERISA attorney who can help you understand exactly what the plan says and how it will impact your disability claim.
Any Occupation Disability vs. Own Occupation Disability
“Own Occupation” Disability
Often, “own occupation” means the occupation you are routinely performing when your disability begins. The insurance company will consider you totally disabled if due to sickness or injury you are unable to perform all of the material duties of your occupation as it is normally performed in the national economy, instead of how the work tasks are performed for a specific employer or at a specific location. There are many variations. For example, the insurance company will consider you totally disabled if a sickness or injury, in and of itself, prevents you from performing the material and substantial duties of your occupation. Your occupation means your occupation or occupations at the time disability began.
“Any Occupation” Disability
Contrast that with “any occupation” which often means you will be considered disabled if you are prevented by bodily injury or sickness from engaging in any occupation for which you are reasonably fitted by education, training or experience. Sometimes any occupation is further narrowed by an earnings qualifier. For example, you must be able to perform that dues of an occupation that will pay to you 60% of your indexed monthly earnings. These definitions are not as difficult to meet the Social Security Administration definition of disability which focuses on “any gainful” employment. Under the Social Security Administration standard, the term “disabled” means a person is incapable of engaging in “any substantial gainful activity” (42 U.S.C. § 423(d) (1) (A)); i.e., the person is entirely precluded from working on a regular basis.
Illustrating the Difference
For example, suppose a software engineer earns $140,000 per year writing complex applications for a tech company. She got into a serious car accident and she suffered a traumatic brain injury. A year later, her condition has stabilized — but she still has cognitive challenges, such as critical thinking skills, short-term memory problems, and is easily distractible. Under an “own occupation” plan, she might continue to qualify for benefits because she can’t do her difficult job. What happens after 24 months, when many plans shift the definition “any occupation” disability. Under a typical “any occupation” definition with an earnings qualifier, or one based on “education, training and experience,” or both, she should still qualify even if she could work as greeter at Walmart. That position doesn’t pay close to 60% of her pre-disability wage. It is not similar employment as a software engineer based on education, training and experience.
If you need help getting copies of LTD plan documents or understanding its long-term disability requirements, Jonathan M. Feigenbaum, Esq. can help. Our practice focuses on ERISA claims and we proudly serve Boston’s disabled workers.
Discuss Any Occupation Disability With an LTD Lawyer
If you need help interpreting your LTD plan’s definitions of disability and gainful employment, contact our office today. We guide disabled Boston workers through their complex ERISA matters. We do this by providing thoughtful and realistic advice at every stage of their claims. If you’d like to learn more about our personalized and thorough approach to long-term disability law, contact us today for a free, no-risk consultation.