Qualification for Long-Term Disability Benefits
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 benefit lawyers of MyLTDbenefits.com have prevailed on the argument that 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. A common example of occupational disability policy language would be, “Due to Injuries or Sickness: (1) you are not able to perform the substantial and material duties of your 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.
“Common Sense Interpretation” of the Term “Occupation”
In a recent D.C. court decision, the court employed a “common sense interpretation” of the term occupation to reject a physician’s argument that his regular occupation should be categorized as an “ER Physician.” The case involved a disability claim by a physician practicing as both an emergency room physician and an internal medicine physician. When the physician became unable to perform his ER duties due to post-traumatic stress disorder, he filed for disability benefits, claiming he was totally disabled from his regular occupation as an “ER Physician.” The court rejected that argument, noting the term occupation, by its very nature was broader than one’s actual job or position. Moreover, the court pointed out that the claimant himself had identified his occupation as “physician” on his disability policy application. Since the claimant remained able to practice internal medicine, the court concluded he was not totally disabled from performing the material and substantial duties of a physician.
In contrast to the above D.C. case, another court determined that the ability of an emergency room cardiologist to perform the duties of a cardiologist was irrelevant in determining his disability. Since the insured could not run to his emergency cardiac patients due to a leg injury suffered in an automobile accident, the court concluded the insured was totally disabled from his occupation as an emergency room cardiologist. We find it critical at MyLTDbenefits.com to examine our client’s specific job duties in terms of quantity and quality in order to properly discern the most important job functions and how those functions align with the limitations of our client.
Independent Medical Examination Required When Reasonable
The insurer’s request that the claimant undergo an independent medical examination must be reasonable under the circumstances, and the claimant may refuse the request provided that he has an excuse which is reasonable. In at least one D.C. case involving a long-term disability plan under the Employee Retirement Income Security Act of 1974 (ERISA), the failure of a claimant to submit to an IME during the claims process, without a reasonable excuse, was considered to be a failure to exhaust administrative remedies and resulted in a dismissal of the claimant’s lawsuit. Before sending our client to an IME, we review the policy language and also determine the extent of the examination in time and depth.
The D.C. court has held that there is no need for the insurer to consult a vocational expert when the long-term disability plan language required a determination of disability to be based solely on the medical evidence. From the perspective of presenting the case on behalf of our client, however, a vocational expert report may be well-advised. The disability benefit lawyers at MyLTDbenefits.com determine the need for a vocational assessment on a case-by-case basis. Given the relatively small cost involved, the vocational assessment is strongly considered as an additional means to substantiate our client’s inability to function in the workforce.
Mental Disability Defined
In a recent bipolar case in the D.C. court, the long-term disability plan defined mental illness as a “mental, nervous or emotional disease or disorder of any type.” The Court of Appeal remanded to the District Court on the issue of whether bipolar was a mental illness, because it was unable to make that determination from the policy language.
Please contact us for experienced assistance with your disability claim. We pride ourselves on providing cost-effective solutions.