Long-Term Disability Policies: Own Occupation v. Any Occupation
Disability claims generally fall into two broad categories: own occupation and any occupation. An own occupation policy typically requires that the insured be unable to perform the material and substantial duties of his or her particular occupation to be considered “totally disabled.” The disability need not render the claimant totally helpless; rather the claimant must be rendered unable to perform the material and substantial duties of his or her particular occupation.
Other policies, sometimes referred to as a general disability policy, create an “any occupation” standard to qualify for disability benefits. These policies typically define disability in terms of the insured’s inability to engage in any gainful occupation that the insured is reasonably suited for based on his or her education, work experience, and other individualized factors.
Most long term disability group policies provide benefits under an “own occupation” clause for the first two years of disability, and thereafter, provide benefits under an “any occupation” clause.
Own Occupation Disability
A crucial question under the “own occupation” provision is how to define the “occupation.” The attorneys of MyLTDbenefits.com have successfully argued that “own occupation” should be limited to the actual work the claimant was performing on the job when the disability arose. In response, an insurer may attempt to argue that a claimant’s “regular occupation” should include the claimant’s occupation as it is performed in a typical work setting for any employer in the general economy.
Any Occupation Disability
Claims under the “any occupation” standard typically involve an analysis of the claimant’s employability. Analysis of these claims by MyLTDbenefits.com, therefore, necessarily focuses on an insured’s education and work experience. The insurer, for example, can consider the claimant’s salary history, as well as a wage analysis of other available occupations, in order to determine what other gainful occupation he or she might reasonably be expected to engage in. Performance of “any occupation” may include workplace accommodations, which may be legitimate grounds for denying benefits. Unless the plain language of the policy is to the contrary, courts generally hold that if an insured is capable of part-time work, then they are not unable to perform “any occupation” and are not totally disabled under the “any occupation” standard.
In many cases, the definition of “any occupation” includes the phrase “gainful” under which the insurer must determine whether or not a claimant can be gainfully employed.
A typical definition of “gainful occupation” is: “an occupation, including self-employment, that is or can be expected to provide you with an income equal to at least 60% of your indexed monthly earnings.” Under this definition, the focus of the analysis is that LTD benefits may be awarded only if the disability prevents the claimant from obtaining work which would enable him to earn 60% of his former salary. Typically, the factors we scrutinize at MyLTDbenefits.com when determining whether a claimant could be gainfully occupied include his abilities, skills and education, as well as an assessment of the labor market in the claimant’s geographic region. Such analysis is typically performed by a vocational expert.
For a detailed analysis of the policy provisions controlling your long-term disability benefit entitlement, contact the attorneys of MyLTDbenefits.com.