Two recent cases – Bedwell v. Schlumberger Grp. Welfare Benefits Plan and Logan v. The Prudential Ins. Co. of Am. – have highlighted the small but pivotal distinction between one’s ability to perform duties in their “own occupation” versus “any occupation” regarding ERISA benefits. Here’s a quick breakdown and summary.
If your policy specifies that it will only pay your long-term disability benefits if you cannot reasonably perform duties in any occupation, your burden of proof will be more difficult. Your doctors and the medical professionals employed by the insurance company who review your claim must both agree that your condition prevents you from doing any work at all.
In these cases, insurance companies will cut off benefits as soon as they determine you are fit to return to some form of work. For example, a construction worker may no longer be able to perform strenuous tasks on a job site, but may be able to do clerical tasks at the office.
It’s not uncommon for the insurance company’s medical professionals to contradict judgments by your doctor, as they are ostensibly working to save the insurance company as much money as possible by limiting payouts. When this occurs, you may have to seek legal recourse.
Less common are policies that will grant benefits if you cannot perform your job, even if you may still be theoretically capable of returning to work performing other tasks. In these instances, the same construction worker above would receive full benefits, even if they find a new job that isn’t hindered by their disability. More likely is that the employer will make additional long-term “own occupation” benefits available under a supplemental disability policy.
In some cases, employers will have a hybrid “own occupation” and “any occupation” policy, making claims even more complicated.
In the case of Bedwell v. Schlumberger, the plaintiff was caught in an unfortunately timed plan change from “own occupation” to “any occupation.” The change meant the termination of his long-term disability benefits. The judge denied the plaintiff’s appeal, pointing out that the plaintiff could work in a different position.
In Logan v. The Prudential Ins. Co. of Am., the plaintiff’s challenge was upheld by the judge, who agreed that she met the criteria for benefits under her “own occupation” policy, despite the insurance company’s assertion that she misrepresented her disability. The plaintiff’s case was bolstered by the fact that the Social Security Administration had agreed with her doctor and awarded disability benefits.
In this case, the judge declined to rule on the “any occupation” portion of the policy, as Prudential hadn’t yet submitted a ruling. The plaintiff was also awarded attorneys’ fees and costs associated with the legal challenge.
If you haven’t already, comb through your policy for the language regarding “any occupation” and/or “own occupation.” If “own occupation” isn’t in the policy, depending on the type of work you do, you may want to explore a supplemental disability policy.