Social Security Disability Insurance (SSDI) approval does not always guarantee LTD approval
Unless your policy says so, don’t expect that you will win your LTD claim just because Social Security approved your benefits. Sometimes, your LTD policy will have definitions of disability that are more difficult to meet, or coverage limitations. You should read your LTD policy in its entirety to understand the eligibility requirements that you must meet. Social Security also takes your age, training, education and experience into account, whereas your disability insurer may not depending on the terms of your policy. That said, a favorable SSDI decision can provide important persuasive evidence for your LTD claim.
Own Occupation versus Any Occupation
One of the most important elements of your policy is the definition of disability. Under most LTD policies, you do not need to be totally incapacitated to receive benefits. There are two main types of definitions of disability – “Own Occupation” and “Any Occupation”. These definitions can vary greatly depending on how your policy is written. Here are the general concepts.
If you are covered under an Own Occupation definition of disability, you qualify for benefits if you are unable to perform the material duties of the job that you were performing at the time your disability began. Most insurers view your job as it is performed in the national economy, not for your employer.
If you are covered under an Any Occupation definition of disability, you qualify for benefits if you are disabled from working in any job, reliably, full-time. Some policies will pay you benefits if you can’t work in a job given your age, training, education, or experience. Others may pay benefits if you can work in a job but cannot earn at least a certain percentage of your pre-disability earnings – this is often referred to as the “gainful occupation” component to a definition of disability. This is only included in some policies, and the percentages of the pre-disability earnings can vary between policies. Be sure to read your policy carefully.
Commonly, LTD benefits will be governed by an Own Occupation definition of disabled for the first 12 to 24 months of your claim. Then, the remainder of the claim will be governed by an Any Occupation definition of disability.
Some LTD policies will pay you benefits if you are partially disabled. The term “partial disability” can be defined differently so read your policy or Plan documents carefully. Commonly, it means that you can perform some but not all of the material duties of your own occupation, or that you can perform all of the material duties, but not on a full-time basis.
Focus on proving disabling symptoms, not diagnosis
Your medical diagnosis alone is probably not enough to qualify you for ERISA LTD benefits. Depending on your policy’s definition of disability, your LTD policy likely requires you to provide evidence of symptoms and functional impairments that prevent you from performing the material duties of your own occupation, or of any occupation, reliably and consistently.
Your medical records are important evidence that the insurance company will review in evaluating your claim. Your treatment providers are focused on your care and probably not your disability claim. It is important that you speak frankly with your doctors about your symptoms – don’t exaggerate your symptoms, and don’t minimize your symptoms. Discuss your claim with them – preferably before you need them to complete claim forms. Let them know how your condition(s) impact your ability to work and that your LTD claim is important to your financial security. Let them know that you are happy to compensate them for their time completing forms.« Return to the ERISA & Insurance Litigation Resource Center
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