Under many disability insurance policies the definition of disability that you must satisfy in order to receive continued disability income benefits changes after as little as 12 months of your claim being paid. Most disability insurance policies begin with what is called an “own occupation” definition of disability, and then change to an “any occupation” definition of disability. This is a very significant occurrence in your disability insurance claim and another common tactic used by disability insurance companies to scrutinize your claim. We regularly see disability insurance companies utilizing this change in definition as an opportunity to terminate payment of benefits. In fact, this is one of the most common reasons that we are contacted by claimants seeking representation against their insurance company by a knowledgeable attorney.
An any occupation definition of disability generally requires that a claimant be unable to perform the substantial and material duties of his or her regular occupation due to injury or illness. There are variations in how this is specifically defined under each policy. For example, the definition may reference the main or essential duties as opposed to substantial and material, etc. Most commonly this own occupation definition of disability governs your insurance claim for the first 24 months, but it may be as short as 12 months or as long as 5 years or more. This definition of disability only requires that claimants provide evidence that supports that they are unable to perform the duties of the occupation that they worked in prior to becoming disabled from that particular occupation. However, the “any occupation” definition of disability is a much more difficult standard of disability to prove in order to continue to qualify for benefits. Generally, an any occupation definition of disability requires that a claimant be unable to perform the substantial and material duties of any occupation for which he or she is or can reasonably become qualified to perform by training, education or experience, due to injury or illness.
For example, if Dr. Jones is a Dentist, then under the own occupation definition of disability he is required to prove that he cannot perform the duties of his regular occupation as a dentist in order to qualify for disability benefits. If Dr. Jones was performing the normal procedures that a dentist would perform, and he developed a tremor in his dominant hand that caused him to no longer be able to perform fillings, extractions, root canals, crowns, dentures, implants, or anything requiring a drill, then Dr. Jones would likely be disabled from his regular occupation as a dentist even if he were capable of performing an occasional cleaning or consultation with a patient. However, if Dr. Jones had a disability insurance policy where the definition of disability changed to the any occupation definition of disability after a certain period of time, then he would not only be required to prove that he is unable to perform the duties of his regular occupation as a dentist but he would also be required to prove that he is disabled from any occupation in light of his training, education and experience. Thus, if Dr. Jones who was disabled from practicing clinical dentistry also taught dentistry at a local college, and was still able to perform the duties required of a college professor of dentistry, he would not usually be considered disabled under this type of any occupation definition of disability.
There is no dispute that the any occupation definition of disability is a much more difficult standard of disability to prove under your disability insurance policy. This is similar to the very stringent standard required to qualify for Social Security Disability Insurance benefits with the Social Security Administration. However, your disability insurance company knows this and often unfairly uses this change in definition of disability as an opportunity to stop paying your disability benefits, which saves the company a considerable amount of money. Countless times our firm is retained to represent claimants whose benefits have been terminated by the insurance company based upon an unjustified allegation that the claimants are not disabled from any occupation, after the company found the claimants to be disabled and entitled to benefits under the own occupation definition of disability.
Suppose that Dr. Jones, the dentist, also had medical problems involving his feet and back, in addition to the tremor in his dominant hand. If Dr. Jones had difficulty with sitting, standing and walking, in addition to problems performing tasks with his dominant hand, then Dr. Jones would much more likely be unable to perform the duties required of a college professor as well as unable to perform the duties of a dentist. However, the insurance company will likely still use this as an opportunity to cease paying benefits arguing that the occupation of a dentist is a more physically demanding occupation than that of a college professor, and that although Dr. Jones is disabled from dentistry, he is not disabled from any occupation given his training, education and experience. Even if Dr. Jones’ treating doctors advise the insurance company that the dentist has restrictions due to his medical condition that prevent him from being able to perform the duties of a college professor, the insurance company will still use this as an opportunity to terminate benefits, likely based upon the company’s own hired doctor disputing the restrictions advised by Dr. Jones’ treating doctors and finding that the dentist can work in any occupation, including as a college professor. This is despite the insurance company’s doctor likely never examining or even speaking to Dr. Jones about his medical condition or restrictions.
The insurance companies are also notorious for putting forth other occupations that it alleges the claimants are able to perform to deny benefits under the any occupation definition of disability, but in reality the claimants do not have the education, experience or training to perform the occupations suggested by the company, and it is not reasonable to expect that they could be re-trained in the occupations. Or, the company may set forth other occupations that it alleges the claimants can perform that are not gainful occupations under the law. In order to be gainful, the person must be able to make a comparable wage to what they previously made, among other factors.
When the definition of disability changes or is about to change from own occupation to any occupation in your claim, your disability insurance company may require you to undergo an independent medical examination, or a functional capacity evaluation. Or, the company may require that you participate in a field or telephone interview with a representative from your insurance company. Your insurance company may insist that you participate in vocational rehabilitation so that you can attempt to return to work in a different occupation. Or, your carrier may only require you to complete extensive claim forms in regard to your past training, education and experience, and for you and your doctors to provide updated medical information and current restrictions. Contrarily, your insurance carrier may never provide you notice of their investigation into the change in definition of disability or request any information from you, and may simply advise you that your benefits have been terminated as the insurance company has determined that you no longer meet the definition of disability under the policy because it determined that you are capable of performing some theoretical gainful occupation. The process of your insurance company re-evaluating your claim to determine whether it believes you meet the any occupation definition of disability in addition to the own occupation definition of disability is a significant occurrence in your disability claim and how it is handled will make the difference as to whether benefits are continued or terminated.
Insurance companies regularly discontinue paying disability benefits based upon the change in definition of disability from own occupation to any occupation. Disability Insurance Law Group has been very successful in fighting these denials where a person’s medical condition disables them from working in any gainful occupation on a full-time basis with reasonable continuity. The earlier that a knowledgeable attorney is retained to prove to the insurance company that the claimant is totally disabled from any occupation the better – in fact, many denials of benefits by disability insurance companies can be prevented if handled correctly during this critical transition period. However, if a termination of benefits has already occured, it is not too late. If an administrative appeal with the insurance company after a termination of benefits at the time of the change in definition of disability is handled properly, a denial can be overturned. If you are facing a change in your definition of disability, or your benefits have been terminated by your disability insurance company, contact one of our attorneys at Disability Insurance Law Group.