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Definitions of Disability in Your Plan Matter

by | Oct 7, 2022 | Firm News

About 40 to 50 percent of employers in the United States offer long-term disability (LTD) insurance policies that promise to provide benefits should a physical or mental condition prevent you from performing the duties of your job. These policies are often underwritten by the nation’s largest insurance companies, such as Unum, MetLife, MassMutual, Northwestern Mutual, Guardian Life, and more.

The one thing that LTD policies offered at work have in common is that they are governed by a federal statute known as the Employee Retirement Income Security Act (ERISA), which establishes ground rules for how insurance companies should process claims. However, it does not regulate what a specific policy may or may not offer in terms of coverage.

Be Informed About Your Insurance

Each insurance company is pretty much free to set its own standards for what constitutes a disability. So, when you sign up at work for an LTD policy, you need to read the summary plan description (SPD) provided with the policy to determine the definition of disability being used by the company underwriting your policy, and also to learn of any limitations in coverage that the policy imposes.

If you buy an LTD policy from a private broker, you will need to enquire about the details of the policy, including the definition of disability being used and also any exclusions or limitations that are being imposed.

In other words, whether you’re purchasing a group LTD plan at work or a private LTD plan on your own, you need to do your homework to understand the parameters of what’s being offered and how that may affect any claim you have in the future. It’s a variation of the ageless warning to “read the fine print.”

If you’re considering purchasing an LTD policy at work or on your own (at work, you generally must sign up during what’s called an open enrollment period), and you want to know what that policy covers and excludes, contact the long-term disability attorneys at Beedem Law. We serve clients in and around Minneapolis, Minnesota; in the neighboring cities of St. Paul and Duluth; and throughout Hennepin County, Ramsey County, Dakota County, and Anoka County.

Relying on our 50 years of experience with LTD insurers and their policies, the attorneys at Bedeem Law can quickly dissect what the policy you’re considering offers, and then advise you of what will be covered, or maybe what will not be covered, and for how long and under what terms and conditions.

Defining Disability

Defining a disability is not always an easy task. Lay people may think of a disability as a physical injury that prevents you from performing the normal duties of your job. While that certainly may qualify, disabilities run the gamut of the human condition from injuries to debilitating medical diseases to mental and emotional disorders – and more.

The Social Security Administration (SSA), which provides what is called Social Security Disability Insurance (SSDI) for those who qualify, relies on a “Blue Book” that lists medical conditions considered disabling. It also relies on a definition that says the disability be claimed must last at least 12 months, or until death, and must prevent the claimant from performing any substantial gainful activity (SGA).

If insurance companies have their version of a Blue Book, they don’t reveal it to the public. Instead, they rely on the wording in their policy – and the interpretation of their claims people – to determine if your condition qualifies.

If this sounds as if insurers have a lot of leeway in defining a disability, you’re right – it does. Nonetheless, insurers are obligated to make a good faith effort to honor claims and to acknowledge when a physical or mental condition rises to the level of a disability.

What Exactly Is Covered?

Each insurance company has some leeway in defining a disability, but in general industry practice, a disability can arise from any number of disorders, including but not limited to: neurological disorders; musculoskeletal disorders; autoimmune disorders; mental disorders; respiratory disorders; cardiovascular and circulatory disorders; digestive disorders; genitourinary disorders; hematological disorders; skin disorders; and more. Disabling injuries are also covered.

Qualifying for Disability Benefits

If you come down with a disorder or suffer an injury that prevents you from performing the duties of your job, you must prove it. This will require not only a statement from your physician, but also complete medical records relating to the disability, such as X-Rays, MRIs, and other test results.

Even if you submit a complete package, the parent insurer will often have the medical evidence you submit parsed by an independent physician or specialist whom they’ve hired. This “independent” review many times will result in a request for more medical evidence, and sometimes will even dispute the finding of your own doctor, in effect denying your claim.

For this reason, it is always best to work with a long-term disability attorney when submitting your initial claim and supporting documentation and evidence. The more complete your package is, the better your chance of being approved on the first try.

Own Occupation vs. Any Occupation

Most policies will contain sections covering the definition of disability as it pertains to performing the duties of your current job – called “own occupation” in the policy – and the definition of disability as it pertains to performing the duties of “any occupation.” In other words, you may qualify for benefits because you cannot perform your current job duties, but you may be able to perform the duties of another job for which you have the training, education, and experience.

Many LTD policies will use a tiered approach toward two categories:

  • For the first 24 months of your disability, for instance, you will be covered because you cannot perform the duties of your current job.
  • After that period ends, you will be asked to seek employment at any job which you can perform.

Still, other policies may pay benefits only if you cannot perform the duties of “any occupation.” The most generous of policies will cover you for as long as you are unable to perform in your “own occupation.” Again, be sure to read the fine print of your policy.

Trusted Guidance Every Step of the Way

From purchasing an LTD policy to filing a claim to launching an appeal when a claim is denied, navigating the administrative hurdles of the long-term disability industry is not something you want to attempt on your own. A lot is at stake should you become disabled, unable to work, and reliant on your LTD insurance to cover your lost wages and ongoing treatment and medical expenses. Get the professional help you need from the beginning of the claims process.

For all your LTD insurance questions and concerns in or around Minneapolis, rely on the resources and knowledge of the disability attorneys at Beedem Law. From first-hand experience, we know how insurance companies operate and can help you obtain the benefits you deserve. Contact us immediately with all your LTD needs.