Long term disability (LTD) benefits are typically provided to employees who are covered by an insurer through their employer or through an individual policy. This type of insurance coverage seeks to protect people who become unable to perform their job responsibilities for medical reasons. Monthly benefits are paid to workers who are covered by this type of policy should they file a successful claim.
“Own Occupation” and “Any Occupation” Policies
Some LTD policies tend to describe disability as the inability to fulfill your work-related responsibilities because of an illness or injury. This is a general description that falls under “own occupation” policies. Most of these policies change after a period of about 2 years from “own occupation” to “any occupation.”
The “any occupation” policies abide by a more rigid definition. Under these, the inability to work in any gainful occupation is reason enough to deny you benefits, even if you cannot work at the job you held before the injury/ illness occurred. Basically, if you can fulfill a “gainful occupation” based on your background and skill set, you are not entitled to these benefits.
What is “gainful occupation”?
Prior to denying you benefits under an “any occupation” policy, your insurer has to prove that you are able to perform an occupation that would pay you at least 60% of what you were making before your disability. Insurers take your educational and vocational history into consideration to determine this.
Understanding “reasonably suited”
From a legal standpoint, being reasonably suited means you are able to conduct the duties of a gainful occupation based on where you live and what skills and limitations you have. Several factors can make a job difficult for you to perform, making the job an unreasonable option.
- If few to no positions that could use your skill set are available within a fair distance from your residence, you may have difficulty becoming gainfully employed.
- If your skills, education, or experience are not sufficient to meet the requirements of a specific job that is available within proximity to your home, you cannot become gainfully employed with the opportunity.
- If you would not be able to make your medical appointments due to your job schedule, you cannot be gainfully employed.
- If your doctor fails to release you to conduct the tasks outlined by the position, you cannot become gainfully employed.
To file a long-term disability claim, it is crucial to present as much accurate medical information as you can that works in your favor to your insurers, including a professional medical opinion by your physician that outlines your limitations. Do not assume that the insurance company will obtain all the relevant records, nor that all your records are accurate. Do not give them the benefit of cherry-picked evidence. This reduces the risk for an LTD claim denial.
Who gets to decide I can work another job?
Insurers responsible for long-term disability benefits work closely alongside vocational experts (VEs) to establish that there are “other jobs” that can employ you and to determine the compensation associated with said occupations.
VEs are individuals with a thorough understanding of the labor market. They depend on several sources to shape their observations. Some of these sources include the Bureau of Labor Statistics, the Dictionary of Occupational Titles, and surveys completed by those who are hiring. Sometimes, these sources are unreliable. Only rarely do VEs paid for by insurance companies find that a disability applicant cannot obtain gainful employment.
As with most situations involving insurance, insurers’ alliances with VEs are not to gather unbiased information. Insurers hire these “experts” with the specific goal of gathering evidence to justify a denial of your claim. In some cases it may be necessary to hire your own VE to counter opposing evidence gathered by the insurer. A resourceful and creative Portland personal injury attorney may know effective and less expensive techniques for demonstrating inability to work as defined in the LTD policy.
