LTD and ERISA Lawyers: Riverside, Orange & San Bernardino Counties
Your Occupation versus Any Occupation
Long-term disability policies (including ERISA policies) typically provide disability benefits based on being unable to perform your own occupation (“own occ”) versus being unable to perform any occupation (“any occ”). Short-term disability (STD) benefits are typically paid when you are unable to perform your "own occupation", and Long-term (LTD) benefits are paid when you are unable to perform "any occupation". Policies differ however on whether "own occupation" and "any occupation" standards need to be met for LTD, and so the policy language will control.
Yet, this is a common point in time where insurers deny/terminate benefits and which is made on the basis that after having conducted a review of the record, (updated medical documentation, and possibly an additional medical provider(s) hired by the insurer), that the insured can perform "some work" or "other work" in the national economy. In other words, even though the insured may not be able to perform his or her past work, there are other less strenuous (physically and mentally) jobs that exist. Bear in mind that if the insurer makes this determination without consultation or analysis of a vocational, medical expert or a change in the medical condition, then this may stand to be challenged.
Your Own Occupation
Although disability policies differ in their language, a typical policy may say you are disabled and entitled to STD benefits if “you are unable to perform with reasonable continuity the substantial and material acts necessary to pursue your usual occupation in the usual and customary way.”
LTD benefits are paid when you are “unable to engage with reasonable continuity in any occupation in which you could reasonably be expected to perform satisfactorily in light of your age, education, training, experience, station in life, and physical and mental capacity, that exists within any of the following locations: a reasonable distance of travel time from your residence in light of the commuting practices of your community; a distance of travel time equivalent to the distance or travel time you traveled to work before becoming disabled; or, the regional labor market, if you reside or resided prior to becoming disabled in a metropolitan area.”
Policies that Do Not Provide for STD and LTD
Many disability policies no longer use the terms “short-term” and “long-term” disability. Instead, they provide for “Total Disability” benefits under an “own occ” standard of disability for a certain period (e.g., 2 years) and then after such period, under an “any occ” standard. Therefore, you must meet the “own occ” standard for the first 2 years (if that is the required period) and the “any occ” standard thereafter and beyond.
If you are not totally disabled and are still able to work, but you are unable to work full-time, some disability policies provide for Partial Disability payments. “Partial Disability” usually means that you are still working, but you are unable to earn at least 80% or more of your pre-disability earnings. “Pre-disability earnings” are usually determined by your earnings for the prior year just before you became partially disabled.
The above definitions are examples of what we usually see in most disability policies. However, it is important to recognize that policies vary from insurer to insurer and that you should have an experienced disability attorney review the terms of your disability policy.