All long term disability claimants should have a good understanding of how their disability insurance policy and/or plan operates. Most ERISA group policies contain similar language describing how it is determined whether a claimant is eligible for benefits or not. Although the language is almost always very much alike, claimants should carefully read the plan documents, in case there are significant variations.
Here, I will discuss two terms that are almost always found in ERISA group policies: "Own Occupation" and "Any Occupation". Most plans provide benefits for the first two years if the claimant is unable to perform his or her "Own Occupation" as a result of an injury or illness. After, these two years, the definition of disability changes. Thereafter, a claimant will only be able to receive benefits if he or she can show an inability to perform "Any Other Occupation".
It must be noted that the two year period (24 months) coverage under the "Own Occupation" definition is the general rule. However, I have seen many ERISA plans that provide benefits under the "Own Occupation" provision for 12 months and several other that insure the claimant for 36 months under the "Own Occupation" provision. I should also clarify that it is common for some plans to use the term "Regular Occupation" instead of the term "Own Occupation". These two terms are very similar however, once again, I must point out it is important read the plan documents carefully because there can be significant variations.
Own Occupation or Regular Occupation:
Beware, the insurance company can trick you with the meaning of the term "Own Occupation". It is extremely important for you as a claimant to define accurately the nature of your own occupation. Do not allow the insurance company to determine on their own what was the specific nature of your job is. You must state the particular physical requirements of your own occupation, thoroughly. Present this information as part of your initial application for long term disability benefits. I see many instances where the insurance company insists in improperly classifiying nature of a claimat's occupation. In many cases, the insurance company will assume that your job is a sedentary job, unless you explain to them what the physical demands of your job are.
I see the problem that I described above all the time, particularly in the medical field. For example: a claimant tells the insurance company that they worked as a "medical secretary". The insurance company goes ahead and determines that being a secretary is sedentary work, when in reality, the claimant's job required him or her to collect laboratory samples, gather medical records, usher patients (some of them in wheelchairs) and walk all over the hospital. Obviously, the insurance company has a better chance of successfully denying your claim if they determine that your case is performed at a lower level of physical exertion.
Any Other Occupation:
In many instances, insurance companies fail to tell you that the term "Any Occupation" only deals with occupations that you are "reasonably" suited to perform. Therefore, under this definition, you are not required to take any specialized training or accept jobs that are too complex for you.
Moreover, in most policies you can still be found disabled if the other occupations available provide you with an income that is below 60% of your earnings before you became disabled. It is important that the insurance company perform a thorough market research of the jobs available in your area. A vocational expert must determine whether the other jobs that the insurance company believes that you can perform can provide you with an income equal to at least 60% of your pre-disability earnings.
