Man Using a Checklist You have a long-term disability (LTD) policy provided by your employer, so when you had an accident that left you unable to work, you assumed you would qualify for benefits to support you until you could return to work. However, despite evidence from your doctor you cannot perform the duties of your job, your LTD claim has been denied. Why is this? It could be because of the fine print.

One or All? The Devil Is in the Details

Buried somewhere in your policy, there will be a clause spelling out the definition of disability. Some policies are much more restrictive than others. A key detail to understand is whether you must be unable to perform all of your job duties or just one. Here is the difference:

  • Every duty. Under this clause, you must be unable to perform each and every one of the “substantial and material acts” of your job to be considered disabled and qualify for benefits. This means that even if you can do only one of the required tasks, your claim could be denied. For example, if your job requires you to stand for several hours, pack boxes, and deliver the boxes to a sorting station, and your doctor clears you for standing but not the other duties, your LTD claim could be denied.
  • At least one duty. A less restrictive policy might require you to be unable to perform just one essential duty to qualify for benefits. In our example above, if you cannot lift goods to place them in a box, you would be disabled, and your claim would be approved.

Determining what the “substantial and material acts” of your job are could be key to getting a claim approved.  

Job or Occupation? What Is the Difference?

Another important detail in an LTD policy could be whether the term used to describe work is “job” or “occupation.” This might sound like nitpicking—because it is—but it could be a key distinction. Your job is the specific position you hold and your particular duties for your employer, while your occupation is a general description of your business or trade. Depending on how each is interpreted by the insurance company considering your claim, it could make a difference in whether you are approved or not. For example, your specific job might require more difficult tasks than the general expectations of your occupation, so you could be approved for disability under the definition of your job, but you would be denied under the definition of your occupation.

The Role of an ERISA Lawyer

While you should understand the terms of your policy before you enroll in an employer-provided plan, when time to file a claim, it is too late to renegotiate your coverage. Instead, your best course of action is to talk to a disability attorney who handles ERISA claims. Monast Law Office brings over 35 years of workers’ compensation disability experience to private LTD insurance claims. You can count on our team to cover all the bases in getting your claim approved. Request our free guide to LTD denials and contact us to learn more.

 

 

James Monast
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Board-Certified Workers’ Compensation Attorney in Columbus, Ohio
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