When you apply for disability insurance benefits, you must prove that your medical or psychological conditions are disabling. In other words, you must show you are unable to work. However, ERISA plans may define disability and work differently. It is important to determine whether your disability plan is an “any occupation policy” or “own occupation policy”.
Before you apply for disability insurance benefits, you should request a copy of your policy’s summary plan description (SPD). The SPD sets out your disability insurance policy’s terms and conditions, including how it defines “disability.” If you need help interpreting your SPD, consider contacting an experienced ERISA lawyer at Uscher, Quiat, Uscher & Russo, P.C.
What Is an “Own Occupation Policy”?
Under a pure “own occupation policy,” you must show that you are unable to perform the material and substantial duties of your job. The insurance company will compare your medical restrictions to your job’s duties. If you are unable to perform even one of your job’s primary functions, you are disabled.
Workers prefer “own occupation policies,” since disability is narrowly defined. It is much easier to prove that you are unable to do your job rather than any job.
However, if you have an “own occupation policy,” you must read the policy carefully. Insurance companies often limit or modify “own occupation” coverage. You (or your ERISA lawyer) must determine whether the following are true in your case:
- There are time limits on your “own occupation” clause (typically two years).
- The definition of “own occupation” has a basis in:
- how you most recently performed your job or how you performed it at the signing of the policy.
- or as how you performed your job, or how others typically perform it in the national economy.
- A return to lighter work would terminate your disability insurance benefits.
This analysis can be complex. If your disability insurance benefits have been denied under an “own occupation policy,” you should contact an experienced ERISA lawyer immediately.
What Is an “Any Occupation Policy”?
Under an “any occupation policy,” you must show that you are unable to perform any and all work within your training and qualifications. This includes the lightest and simplest jobs in the national economy. It is more difficult to qualify for benefits under an “any occupation policy.”
To prove that you are unable to do any occupation, you must show that you cannot even perform sedentary work. The Department of Labor defines “sedentary work” as work that involves lifting of no more than 10 pounds at a time with occasional lifting or carrying articles like files, notebooks and small tools. Sedentary work is typically sit-down work.
If you have coverage under an “any occupation” plan, the insurance company will evaluate your work history, education and skills. If you are able to do work (even part-time or accommodated work), you may be denied disability benefits.
However, “any occupation” plans sometimes require that you be able to perform a “gainful occupation.” Gainful occupation clauses limit the “any occupation” analysis and can subsequently lead to an award of disability insurance benefits. Typically, a “gainful occupation” pays 60 to 80% of your pre-disability earnings.
“Gainful occupation” clauses are particularly helpful for high wage earners. For example, a software engineer made $150,000 before suffering a traumatic brain injury. Post-injury, the engineer is limited to simple work, earning roughly $20,000 per year. If the engineer’s “any occupation” policy requires gainful employment, he or she may still be disabled.
“Any occupation” policies are both complicated and nuanced. If your disability insurance plan contains “any occupation” language, you may want to hire an experienced NJ ERISA attorney to review both your case and policy language. Your attorney can evaluate your eligibility, as well as guide you through the claims process.
What Is a Vocational Expert?
During the disability claim process, a vocational expert may evaluate your ability to work. A vocational expert is not a doctor and cannot assign work restrictions. Instead, he or she is a trained human resources professional that:
- Reviews a set (or series) of work restrictions and
- Advises about the availability of work within these restrictions.
If you have coverage under an “own occupation policy,” the vocational expert will determine whether you are capable of doing your own job — and may define what your occupation involves.
If you have coverage under an “any occupation” policy, the vocational expert will consider your ability to work within the national economy. Typically, the expert will perform a transferable skills analysis as well as a labor market survey. The transferable skills analysis considers your training and skills and assesses your ability to transition to other work. A labor market survey evaluates the availability of work within your skills and restrictions.
A vocational expert’s opinion can seriously impact your claim. A vocational expert may redefine your job to include lighter or sedentary activities, allowing for a denial of benefits. Other times, a vocational expert may over emphasize or misconstrue your training and qualifications, leading to a denial.
Sometimes, your ERISA lawyer may hire a vocational expert to evaluate your disability insurance claim. Your lawyer’s vocational expert may counter the insurance’s company’s assessment and support a finding of disability.
Can the Terms of a Disability Insurance Policy Change?
Many long-term disability insurance policies start as “own occupation” plans. However, they may convert into “any occupation” plans after a period of time (typically after two years). This conversion can result in a denial of benefits.
If you are denied disability insurance benefits, you have appeal rights. Your initial appeal is filed with the insurance company. If you are again denied, you may file a federal court appeal.
ERISA plans and SPD documents are difficult to understand. They often contain “legalese” and include many complicated technical requirements. Additionally, the ERISA claims process has strict filing, appeal and evidentiary rules. If you fail to meet these requirements, you may lose your right to benefits. If you are considering a disability insurance appeal, you should speak with a lawyer.
To Learn More, Speak to an NJ ERISA Lawyer
If you have questions about the terms of your disability insurance policy or need help with an ERISA claim, you should contact an experienced New Jersey ERISA lawyer. An attorney can advise you of your rights and file your ERISA claim or appeal, as well as give you a fighting chance against the insurance company. Contact Uscher, Quiat, Uscher & Russo, P.C. today.