By Iván A. Ramos

All long term disability (LTD) claimants should have a thorough understanding of how their LTD plans operate. Most ERISA (Employment Retirement Income Security Act of 1974) group policies are composed of similar language that specifically outline how a claimant’s benefit eligibility is determined. However, while this language is mostly the same between these policies, significant variations can appear at times. For this reason, a claimant should make certain to carefully study his or her plan’s documents.

I will discuss in this article two terms that are almost always found in ERISA group policies: Own Occupation and Any Occupation. Most plans will provide benefits for the first two years if a claimant is unable to perform his or her “Own Occupation” due to injury or illness. At the expiration of this initial time period, the definition of disability changes. Subsequently, a claimant’s benefits will only continue if he or she can prove an inability to perform “Any Occupation”.

Coverage for 24 months under the Own Occupation definition is simply the general practice in the disability insurance industry. However, I have seen many ERISA plans with provisions that provide benefits under the Own Occupation Provision for as few as 12 months, and as many as 36 months. Please also note that it’s common for some plans to use the term Regular Occupation instead of Own Occupation. As I have discussed, these phrases, while usually similar, can still at times have different meanings. For this reason, I must reiterate the importance of carefully reading your plan’s documents.

Own Occupation or Regular Occupation:

Please be aware that insurers might attempt to misinterpret the meaning of Own Occupation to their financial benefit. Note that the manner in which your job is performed can be the subject of extensive debate. Therefore, it is vital for claimants to carefully define the nature of their occupations with specific descriptions of the physical and intellectual demands of their jobs. Do not allow an insurance company to determine how your own occupation is performed without your input. It is a good idea to provide the disability insurance company with a thorough account of your vocational responsibilities.
I have come across numerous instances in which the insurer tries to improperly classify the true nature of a claimant’s occupation. Unless you fully explain what the physical demands of your job consist of, the insurance company will often assume that your job is far less demanding than it actually is.

I see the problem that I have described above with claimants from numerous occupations. Very often, I encounter this problems with claimants with occupations in the medical field.

Here is one example that I have seen in several instances: a claimant informs the insurance company that he or she worked as a medical secretary. The insurance company then automatically takes the word “secretary” at face value, and determines that the job is sedentary in nature. However in reality, the claimant’s job required him or her to walk all over the hospital collecting laboratory samples, gathering medical records and escorting patients –some of whom are in wheelchairs. Based on the wrong assumption that the job was sedentary, the insurance company denies the claim. Clearly, if the claimant had forcefully explained the true nature of his or her duties, the insurance company would not have been able to deny the claim.

Any Other Occupation:

Insurance companies often fail to tell you that the term Any Occupation usually deals with occupations that you are “reasonably” suited to perform. Therefore, in many cases the insurance company cannot assume that you will be retrained or that you can accept jobs that are overly complex for you. Moreover, most plans will still consider you disabled if other jobs that you can perform provide an income which is below 60% of your pre-disability earnings. In these cases, insurance companies must perform comprehensive market research of the jobs available within a claimant’s local area. At that point, a vocational expert is required to determine whether jobs that the insurer believes you can perform also match a certain income level.