Long Term Disability: The Surprising Complexity of an Insurer’s Definition of Disability

An incredibly common tactic used by long-term disability (LTD) insurance companies to deny claims is the “own occupation”/”any occupation distinction.” Under the vast majority of LTD policies, the insurer will pay you for up to 24 months if your disability prevents you from being able to perform the material duties of your "own occupation." However, after 24 months the standard changes, and you must be unable to perform the material duties of "any occupation" based on your education, training, experience, and limitations due to your disability.

Typically, an insurer will perform a re-evaluation around the 24-month mark. One of their in-house doctors will likely come to the conclusion that while your disability prevents you from doing your old job, your current medical status would not prevent you from performing a less physically demanding job. There might also be a vocational analysis identifying the jobs the insurer thinks you are qualified to do at this time. Typically, this type of denial is based on a claimant’s actual medical status. However, we are now seeing “any occupation” denials based on a claimant’s hypothetical medical status.

A client of ours was recently denied LTD benefits based on the “own occupation/any occupation” provision in her policy. The denial letter stated that if she chose to undergo an entirely optional surgical procedure, she would potentially recover in 4 or 5 months, and thus she would promptly be able to return to work at a sedentary job.

Facts ignored by the insurer:

• this surgery only has a 50/50 success rate;
• the insured has already undergone multiple surgeries in the past with very limited results;
• this surgery would only address one of the many physical problems;
• the insured is choosing not to have the procedure done because of her past surgical experiences;
• the insured cannot actually perform the material duties of any occupation (sedentary or otherwise) at this time;
• Social Security deemed the insured permanently disabled.

Unfortunately, all of this significant information was discounted by the insurer. They continue to believe that if the insured has this surgery, she will recover in 4-5 months and she will certainly be able to work again.

It’s difficult enough to prove to an insurance company that under your current condition, you meet their definition of disability. Imagine how difficult it can be when your insurance company makes their determination based on where they think you will be several months down the road - after your hypothetical surgery and hypothetical recovery?

If your long term disability insurance claim has been denied, please do not hesitate to contact our office for a no-cost consultation.

We understand, and we can help.
www.kantorlaw.net (800) 446-7529

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