An insurer’s definition of disability

Those who suffer from an autoimmune disease often fight two battles:  coping with a debilitating illness and explaining their invisible, debilitating pain to others.  Most disabling symptoms are self-reported rather than objective.  But, as any individual living with chronic pain will tell you, this lack of objectivity does not mean that their disability is not real, incapacitating, or life changing. 

Unfortunately, the imperfections with diagnosis, treatment, and understanding of autoimmune illnesses (such as rheumatoid arthritis) create a perfect foundation for insurance denials.  Many people don’t realize how often insurance claims are denied, assuming instead that insurance companies will do the right thing.  Regrettably, this is not the case.  The burden of proof, whether it is convincing a stranger or your insurance company, belongs to you.

If applying for long term disability benefits becomes a necessity, it will be beneficial to understand how your long term disability policy defines disability.  Many disability policies contain two different disability standards based on the length of the claimant’s disability, but some contain only one or the other:

  • “Own occupation” – You will be required to prove that your illness or injury prevents you from performing the material duties of your own occupation, not necessarily the job as you were performing it for your employer. Many policies limit this definition to the first 12 or 24 months of disability benefits.
  • “Any occupation” – You will have to show that your illness or injury prevents you from performing any occupation, usually considering your education, training, and experience.  Sometimes the policy will limit the any occupation definition to “gainful” occupations, meaning the ability to perform occupations in which the claimant would earn less than a defined amount will not be considered in evaluating the claim.

It will be your responsibility to provide evidence to the insurer that you meet the applicable definition of disability.  If you are initially unable to do so, you might refer to our previous blog post, “What To Do When Your Long Term Disability Claim Has Been Denied.”  There, we discussed important ways to gather and submit evidence which may help you meet your burden of proof. See http://www.creakyjoints.org/blogs/blogs-front-page/blogs/insurance-matters/ for essential steps to follow when building an appeal packet.

At Kantor & Kantor, our attorneys have become focused and tireless advocates for those who have been wrongfully denied their long term disability benefits.  If you have questions about your long term disability denial, call us at (800) 446-7529 or learn more at www.kantorlaw.net.  We offer no cost consultations, and we work on a contingency fee basis, which means you don’t pay us a fee unless we get your claim paid.    

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