What Does “Gainfully Employed” Mean?

Does Your Disability Claim Hinge on the “Gainful Employment” Definition?

For those who are applying for or making a claim on a long-term disability policy, one term can be particularly troublesome: gainful employment. What does it mean to be “gainfully employed”? On some basic level, we all have an idea of the gainful employment definition. But in legal terms, it may not be so superficially obvious.

If you have questions about disability, the attorneys at Uscher, Quiat, Uscher, & Russo can help. Contact us today to learn how we can help.

Two Types of Long-Term Disability Insurance Policies

Long-term disability policies come in two different types. The exact wording on your policy contract is important. The first type pays out in the event that you are no longer able to do your current job. The second type of policy pays out in the event that you cannot do any job.

Typically, policies are a bit of a hybrid. They pay out for a couple of years if you are no longer able to do your current job. After that, in order for the policy to continue to pay out, you must not be able to do any job.

In either case, the question of gainful employment reigns supreme. If you are capable of finding any gainful employment given your level of education and other factors, you will be denied that policy.

At first glance, it sounds like nothing short of being comatose would fit that definition and it’s true that the definition is extraordinarily narrow. But what exactly does it mean? Let’s try to unpack it.

“Gainful Employment” Definition

According to most policies, a “gainful occupation” is one that is capable of providing you with at least 60% of your wages. In other words, if your a neurosurgeon, the insurance company will not be able to point at the “help wanted” sign at the local Burger King and say: “Hey, there’s a job opening right there.”

This means that in order to terminate your long-term disability benefits or deny a claim based on an “any occupation” clause, the insurance company must demonstrate that there is some job that the individual can do that would net them 60% of their pre-disability wages.

What Does “Reasonably Suited” Mean?

The next language that deserves more scrutiny is “reasonably suited.” Reasonably suited considers a number of different occupational questions. These include your level of education, training, your abilities after the disability, and your capacity to perform the requirements of a job given your disability. It also depends on your location as well.

The better question then is what makes an individual “unreasonably” suited to a job? These would include:

• There are no examples of the occupation you would be suited for within a reasonable distance to your home;
• The requirements of the job are beyond your educational skills or require experience and training that you don’t have;
• The job interferes with your medical treatment;
• You have not been given a doctor’s release to perform the required tasks at the position.

Who Decides Whether You Are “Reasonably Suited” to Perform Work?

The big question you probably have is “who decides if you are reasonably suited to do a job at 60% of your past wages?” Long-term disability insurance companies staff vocational experts who take a look at the job market and assess your skills. They make an argument that you can do such-and-such job with your experience and educational background. On that basis, they may deny your claim or stop payments. You can, of course, appeal that decision. At that point, the case would go before the courts and a decision would be rendered by a judge.

Talk to a Long-Term Disability Attorney

The disability attorneys at Uscher, Quiat, Uscher, & Russo have advocated on behalf of several clients who were unfairly denied claims or had their payments stopped based on the “any occupation clause.” We know that far more often than not, folks would prefer to be working if they could. Insurance companies should not be able to dictate when their policies pay out. Insurance policies are legally binding contracts. If you’ve had your benefits cut off or denied, contact us today. We can help.