Certain terms and conditions are typically present in most policies, even though long-term disability insurance policies differ in many respects. The exact wording in these terms may be different from policy to policy, but the concepts that are described by these coverage terms are frequently litigated issues in claims litigation.

Own Occupation

Initially, the claimant’s own occupation determines disability under most group policies for a limited period of time. But later, any occupation determines disability. Nowadays, group policies look at the national economic statistics and averages as opposed to the claimant’s particular job. It is critical to be aware that in evaluating the physical and mental demands of their particular occupations, insurance companies may use inaccurate and overly generalized job descriptions. So during the claim process, it is important to ensure that the insurance company utilizes correct occupational descriptions to evaluate your disability.

Any Occupation

To be entitled to further disability benefits after about twenty-four months, most long-term disability insurance group policies require a claimant to be disabled from any occupation. Any occupation is defined as one that the insured could reasonably engage with their training, experience, and education. A vocational analysis can be used by the insurance company to determine the transferable skills that the claimant could use in a different occupation. In this case, the insured could go through a vocational assessment completed by a vocational rehabilitation counselor of the claimant’s choosing.

Education, Training, and Experience

California common law and most long-term disability insurance policies and the insured’s education, training, and experience must be taken into consideration in determining whether one is disabled from any occupation. It is necessary to evaluate whether the designated occupation is truly comparable in view of the insured’s station in life if the benefit claim is denied on the basis that the insurer may engage in an alternative occupation.

Comparable Earnings

The long-term disability insurance company may specify an alternative occupation that is compensated much lower than the insured’s former job. In this case, the claimant may have a reason to state that an alternative occupation identified by the long-term disability insurance companies is not suitable in view of his education, training, and experience.

Age Limitations

When a claimant is over 50, there is a question of whether they can actually perform a certain job because of their age. This can be analyzed and determined by conducting a local market review.

Other Limitations

It is important to be educated about the possible limitations because long-term disability insurance companies may incorrectly classify a disability, which will limit their liability for an otherwise legitimate claim. Most long-term disability insurance policies contain other benefit exclusions and limitations regarding particular disabilities. One of them is a pre-existing condition exclusion which is often a reason for denial of the claim. And many policies specify mental/nervous limitation as something that limits the length of time when an insured may receive benefits under the long-term disability insurance policy.

Pre-Existing Conditions

If a claimant received consultation or medical treatment related to their disability during a specified period of time just prior to coverage, then under most policies, the disability will be excluded from coverage. Sometimes when a claimant just experienced symptoms that would have caused a reasonable person to have sought medical treatment or advice, long-term disability insurance policies include these situations in pre-existing conditions terminology.

Self-Reported Injuries

Self-reported symptoms might be limited in many insurance policies, especially the newer ones. They might contain a provision limiting coverage for any disability due to a sickness or injury reported by the insured. They are talking about the issues that cannot be documented or quantified by objective medical testing, such as MRIs, blood tests, x-rays, etc. If this situation describes your case, you might want to get your condition independently verified either by testing or other means. Your physician should be able to let you know if this is possible, and if it is, the best thing to do is to complete the verification identified by the doctor and then submit the verification to the insurance company.

Mental/Nervous Condition

Sometimes long-term disability insurance policies will limit coverage for a disability related to or caused by a mental/nervous condition. There are two aspects to take into consideration here. Check what is defined as a mental/nervous condition in the long-term disability insurance policy and check if the policy contains a definition for mental/nervous condition in the first place.

What is a Mental/Nervous Condition – It is critical to review how this provision is set forth in the policy. The language might be limiting, and in this case, it can only be invoked when your disabling condition is due exclusively to the mental/nervous condition.

The Definition of a Mental/Nervous Condition – The term mental/nervous condition should be appropriately defined in those cases when the policy limits coverage for disabilities caused by mental/nervous conditions. The correct definition should specify whether one is to look at the symptoms of the disability, its cause, the form of treatment, or all of these factors combined.

Residual (partial disability) benefits – A claimant might be disabled but continue to work, and many policies include a provision allowing for the receipt of benefits in this case. The term for that is a residual disability benefit. It is only valid if the claimant suffers an actual reduction in monthly income due to the disability, usually at least 20 percent. Sometimes a reduction in the number of hours the person can work is also a requirement. The policy needs to be reviewed to figure out the proper amount of benefits if the worker makes such a claim and qualifies for residual benefits. The benefits under a residual disability provision are often calculated differently than that for total disability benefits.

At Bonnici Law Group, we’ll assist with any questions you may have about long-term disability so you can decide what is best for you and your family. Call us at (619) 259-5199 or click here for a FREE consultation!