Important Long-Term Disability Insurance Terms You Should Know
- By ADMIN
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- 27 Feb, 2019
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When most people think about disabilities, they might think of different maladies, such as paralysis, loss of limbs, or blindness. However, you may have a less traumatic disability that still qualifies you under the terms of your disability insurance policy. This can include illnesses such as asthma, arthritis, issues with pregnancy, and depression, or injuries such as broken bones.
When you enter a long-term disability plan, you should fully understand exactly the language within your policy so you know your rights. The following are some terms you should know regarding legal definitions in most ERISA long-term disability policies, both individual and employer-sponsored.
What Is a Disability?
A disability is any qualified illness or injury that occurs that leaves a person or employee unable to perform his or her job. A disability also applies to an individual who is unable to earn a specific percentage of income while employed at his or her normal job.
What Is a Preexisting Condition?
A preexisting condition is a type of injury or illness where you received treatment or should have received treatment during a time before your insurance became effective. The amount of time will be different based on your insurance plan's policy.
What Is an Injury?
An injury is any accidental hurt or sickness that is a direct result from a qualifying accident under your policy. If you were hurt and not insured, then you were hurt again in the same part of the body, your long-term disability insurance may not cover you. This is dependent on individual policy language. Be sure to check your policy to see if this the case for you.
What Is a Physician?
A physician is a licensed doctor who provides treatment for your illness or injury in his or her licensed area of practice. A physician cannot be your husband or wife, in your immediate family, or someone living in your home.
Additionally, if you have to provide a physician statement to validate your disability claim, the statement will not be considered if the statement is from a relative or member of your household.
What Is a Regular Occupation?
A regular occupation is a job where you worked at the time of your disability. ERISA group policies typically define an occupation by the work done on a national level rather than the tasks you specifically perform in your occupation. However, some insurance policies define regular occupation by the tasks you specifically perform for your employer.
The definition of regular occupation can be crucial when you fight for your long-term disability benefits. For instance, if you are a banker and your firm provides special courier services to different clients, the scope of that job is different from what bankers normally do.
If you drive to a client carrying heavy boxes of documents and you fall and break your back in the course of your job and you can no longer do this portion of your occupation, whether or not you will get long-term disability benefits will highly depend on your insurance company's definition of regular occupation.
Specific examples of terms in a long-term disability policy are important to know and are often different than you would normally use in your normal life. Before you file a claim for your disability insurance, understand these definitions to make sure you protect your rights.
If you have any questions about long-term ERISA disability insurance or if you are having trouble making a claim on your policy, please contact us at Scott E. Shaffman Attorney At Law. We can help you understand the definitions and coverage of your insurance and take up your case for your disability claim.
The language in a disability policy can vary from one insurance company to the next. This can make it difficult to determine exactly what your disability benefits are when you have sustained a serious injury.
Two common areas of confusion in long-term disability policies are the definitions of occupation and job duties. Legal arguments in long-term disability claims often center on the definitions of occupation and job duties, so you need to be able to understand the language in your policy if you want to know your rights.
Own-Occupation vs. Any-Occupation
When it comes to defining a disability, most policies will provide benefits for either an own-occupation disability or an any-occupation disability. If your disability policy can be classified as an own-occupation policy, you will be able to obtain benefits if you sustain an injury that prevents you from performing the duties associated with your current occupation.
This means that even if you are able to obtain a position in another occupation, you can still apply for disability benefits because of your inability to continue to work in your chosen field.
Many long-term disability policies are categorized as any-occupation policies. If the language in your policy refers to any-occupation coverage, you will only be able to access benefits if you are unable to work in any capacity.
You may need to work with your attorney to have the court qualify your policy to require the insurer to provide you with benefits if your injuries prevent you from obtaining a job for which you have sufficient education, training, or experience.
The level of disability required to obtain benefits differs between an own-occupation and an any-occupation policy, so you should know which type of language is used in your policy before you file a claim.
Material Duties vs. Substantial Duties
Long-term disability insurance policies will often state that benefits can only be obtained when a claimant is unable to fulfill the material and substantial duties of their occupation. Though it sounds like these duties are lumped together, many insurance companies evaluate them on an individual basis.
Material duties are categorized as those tasks that must be done as part of an occupation. In other words, if you couldn’t complete the material duties of your job, it would be impossible to do your job the right way.
Substantial duties are important to job performance but don't encompass the entire job description. For example, if you were a sales representative who had a stroke and lost the ability to speak, you would be unable to perform the substantial duties of your job. You may still be able to interact with clients via email, however, so not all aspects of your occupation would be impossible.
There is a lot of overlap between material and substantial duties. Your attorney should be able to establish the specific duties that you fulfill at work each day if you file a disability claim. Showing how your workday differs from a watered-down and generalized job description will help you prove your claim more effectively.
The outcome of a disability claim depends, in large part, on the specific language used in the claimant's insurance policy. Occupation descriptions, essential job duties, and what defines a disability can vary from one policy to the next.
An attorney can help you better understand whether your policy uses own-occupation or any-occupation language, and whether or not your disability limits your ability to complete material duties, substantial duties, or both.
Contact Scott E. Shaffman, Attorney At Law to schedule a free consultation so you can learn more about the specifics of your long-term disability policy.
