The Fine Print of Policy Language: How Disability Insurers Use Ambiguities to Their Advantage

Disability insurance policies contain terms that appear clear at first glance—phrases like “own occupation,” “reasonable care,” and “ongoing proof of loss.” However, these seemingly straightforward terms can carry hidden meanings that give insurers broad discretion to challenge claims, delay benefits, or deny coverage altogether.

At Disability Insurance Law Group, our claims attorneys help policyholders nationwide identify and challenge the vague or misleading policy language that insurers often use to avoid paying what’s owed. If you’re pressured to return to work, provide repeated documentation, or comply with unclear requirements, your insurer may use the fine print to tip the scales in their favor.

“Own Occupation”: What It Says vs. What It Means

The definition of your occupation may determine whether you qualify for benefits, but it’s rarely as simple as it sounds.

Many disability insurance policies claim to provide coverage if you cannot perform the “material and substantial duties” of your own occupation.

But the way “own occupation” is defined can vary significantly:

• Some policies consider your occupation as it exists in the national economy rather than how you actually perform it.
• Others shift the definition to “any occupation” after a specific period, usually 24 months.
• Some do not recognize specialized roles—for example, they view a neurosurgeon as a generic physician or a trial lawyer as simply an attorney.

These subtle shifts can drastically change your eligibility. Insurers may argue that you can still work in a related job or a generalized version of your profession, even if you can no longer perform the duties for which you were trained.

“Reasonable Care”: A Moving Target Used to Monitor Compliance

Policies often require the insured to be under “appropriate” or “reasonable” care, but this phrase leaves room for interpretation.

Insurers may use this clause to challenge your medical treatment plan or pressure you to pursue unnecessary, risky, or invasive treatments.

They might deny your claim for failing to:

• See a specialist even if your primary doctor is managing care effectively.
• Undergo surgery or treatment that you have declined for valid medical or personal reasons.
• Follow a treatment schedule that the insurer—not your doctor—deems sufficient.

What constitutes “reasonable care” can become a tool to second-guess your physicians and question your ongoing eligibility for benefits.

“Ongoing Proof of Loss”: A Justification for Endless Requests

Even after benefits are approved, most policies require “ongoing proof of loss,” but insurers can exploit this clause to wear claimants down.

Requiring periodic documentation is not unreasonable. But when insurers demand excessive paperwork, repetitive medical records, or ongoing evaluations with little justification, it becomes a tactic to delay payments or push claimants to give up.

Cancer survivors, those with chronic illness, and individuals with stable long-term conditions often face repeated scrutiny, even when their condition hasn’t improved. We help clients respond strategically and push back when insurers abuse this clause.

Know What You Signed—and How to Fight Back

Policy language isn’t neutral—it’s a strategic tool insurers use to protect their bottom line.

You’re not alone if your claim has been denied, delayed, or challenged using vague or shifting language. At Disability Insurance Law Group, we specialize in decoding complex policy terms and holding insurers accountable to their promises.

Contact us today at 954-989-9000 or online to schedule a consultation and learn how we can help you challenge ambiguous policy terms and fight for your rightfully owed benefits.