Deciphering the different definitions of disability is a surprisingly complicated process. Some of these definitions can be found in almost every policy, while some use attachments or riders to tweak the policy language. While the exact terminology may be different, there are five basic definitions of disability that are important to understand if you’re considering filing a claim for benefits or even if you’re just trying to decide what type of coverage to purchase.
- Own Occupation. Simply put, this definition defines you as totally disabled if you can no longer perform the material and substantial duties of your occupation. Some policies will even consider you totally disabled if you are unable to perform just one of the material and substantial duties of your occupation. If you are being paid benefits under an own occupation disability policy, you may be able to go back to work in a different type of job and still be entitled to benefits as long as you’re unable to perform the job from which you were declared totally disabled. Because of this liberal definition, these policies are usually more expensive and harder to obtain.
- Any Occupation. This definition is almost the opposite of Own Occupation. You’re only considered totally disabled if you cannot perform the duties of any occupation. Usually, the policy will include language that takes into consideration your education, training, experience, and earnings level as well. This prevents the insurance company from trying to envision you in a job for which you’re under-qualified or over-paid just to end your claim. This definition is often found in cheaper, group policies and can be challenging to collect benefits without strong medical evidence and very debilitating conditions.
- Split Definition Coverage. While this isn’t a definition of disability in and of itself, this definition is very common in disability insurance policies so it’s worth discussing. Many policies have definitions of disability that switch from Own Occupation to Any Occupation after a period of time that can range from 6 months to 5 years. Anyone receiving disability benefits under this type of coverage should be extremely wary leading up to this transition date, as insurance companies often plan for how to stop paying benefits around that time.
- Presumptive Total Disability. Regardless of your policy definition of disability, certain catastrophic injuries or illnesses are automatically considered totally disabling. These often let you skip some of the requirements that must be met to be considered totally disabled. You’re allowed to receive benefits immediately after the elimination period that will continue even if you return to work. The medical events that fall under this definition include the loss of sight in both eyes, loss of hearing, loss of speech, the use of both hands, the use of both feet, or the use of one hand and one foot. These losses must be complete. Different policies can have slightly different qualifications for Presumptive Disability and not all of the ailments listed above will qualify under every policy.
- Residual Disability. The first four definitions have been about Total Disability, but this isn’t the only way to qualify for benefits. Some policies include definitions of disability that will pay you a portion (or all) of your benefits if your work level and/or earnings are reduced. Under Residual Disability, claimants are paid benefits based on the relative amount of income they’ve lost due to their disability. This is calculated through a formula that takes into account the disabling condition and the percentage of pre-disability income the claimant continues to earn. Be aware – some cheaper policies include a clause that requires the claimant to have been totally disabled for a while before they’re able to collect residual disability benefits. There are two ways to purchase Residual Disability coverage: you can either purchase a Total Disability policy with a Residual Disability rider or you may purchase what is often called an income replacement policy. Income replacement is another term for residual coverage and can be the cheaper of the two option since it lacks specific Total Disability coverage.
- Partial Disability. This definition is very similar to but slightly different from Residual Disability. The main difference is that Partial Disability does not consider the loss of income calculations when determining the benefit amounts. Rather, if you’re considered partially disabled, the policy will pay you 50% of the total disability benefit amount. Partial Disability is also not offered as a standalone policy and is either included as a rider to a policy or as the base coverage in some rare policies. Benefits periods for Partial Disability are often much shorter, usually not extending beyond 6 to 12 months.
Even if your injury or illness may fit into one of these policy definitions, it doesn’t always mean you will receive benefits. There are many other policy considerations, such as appropriate care or diagnosis limitations, that can decide whether or not you’ll be able to collect your benefits. If you’re considering filing a disability claim and are not sure of the definitions in your policy, or if you’re not sure if you qualify for benefits under your policy’s definition, please call our firm toll-free at (855) 828-4100 or sign up for a free consultation on our website. We can help you get the answers you need to get the benefits you deserve.
Posted in Resources
- Tagged benefits, claims process, definitions, Disability, disability claim, disability insurance, doctor, examiner, filing a claim, residual disability, tips, total disability
We have encountered several cases where claimants have been denied their benefits not because of incomplete or inconclusive evidence of their medical conditions but solely because their conditions kept them from working longer than the guidelines used by disability insurance claim departments. When evaluating disability claims, claims examiners rely on industry developed resources to determine the expected duration of the claim, regardless of the specific circumstances. Based on these claim management practices that have been put into place by most insurance companies, we’d like to shed some light on the process used to assign expected return to work dates for claims and the extra steps that claimants need to take to protect their benefits if they’re disabled beyond these arbitrary dates. Continue reading
Posted in Resources
- Tagged agents, appropriate care, benefits, claim denial, definitions, Disability, disability insurance, doctor, examiner, Functional capacity evaluation, Insurance, insurance company, Job description, tips, unum provident
We’ve often mentioned insurance company investigators and their tactics as extremely adept at developing reasons to deny legitimate disability claims. Insurance companies like to hire former FBI agents and police detectives who have been specifically taught to treat their targets as adversaries and be cynical of any answers – which they innocently refer to as being professional. These investigators have undergone specialized training on how to dig up information and how to conduct interviews that can be twisted against claimants and used by claims examiners to deny disability claims. Due to our connections, our firm has seen some of the confidential training materials used by disability claims operations that help provide insight into the investigative techniques and methods used to interview claimants. This information can be invaluable to claimants, allowing them to more properly prepare for the interview, whether it’s a scheduled appointment or an unannounced visit. Today’s blog is going to breakdown and summarize some of the key points to help you handle an interview and understand the underlying purposes for the questions. Continue reading
Posted in Resources
- Tagged appropriate care, benefits, claims process, Disability, disability claim, disability insurance, examiner, filing a claim, Insurance, insurance company, loss of income, Pain Management, profits, reources, settlements, surveillance, tips, total disability
We have talked previously in our blog about the dangers social media can pose for your disability claim. As summer kicks into gear and many people enjoy outdoor activities and vacation traveling, it’s important to revisit some of the social media points we’ve made in the past and provide some new insight into how different Internet sites may be able to help your claim and improve your odds of obtaining the disability benefits you deserve. Continue reading
Posted in Resources
- Tagged agents, brokers, Cigna, claims process, disability insurance, filing a claim, Google, Instagram, Insurance, insurance company, LinkedIn, Medical News Today, settlements, tips, Twitter
During this time of year, many people have questions about the tax effects of their disability benefits and how they can be reported on their tax returns. Many of these questions are addressed by one of our partners, who’s a Certified Public Accountant. These answers may help you with some of the issues that may come up with your benefits and the related income taxes. Continue reading
What a difference a year makes! Where does the time go?
We’ve been writing articles for this blog for over a year, and we’ve learned as many things from our readers as we hope you’ve learned from us. As our topics have grown and more readers have found us, we wanted to make sure that some of our posts don’t get lost in the noise of the Internet and buried deep away where claimants would less likely be able to find help. In the spirit of the NCAA basketball tournament, we’re going to go through our most popular blog posts as well as highlight some posts that we think include topical, valuable information that may be helpful in your disability claim. Thanks again for reading our blog over the past year and making us one of the top-rated destinations for disability claim advice and help. While we hope you never have any problems with your conditions or your claim, we’ll continue to be here to read, just in case, for years to come!
Posted in Resources
- Tagged back pain, CFS, chronic fatigue syndrome, chronic pain, claim denial, claims process, definitions, Denial, disability insurance, examiner, fibromyalgia, Insurance, Pain Management, reources, residual disability, settlements, social media, surveillance, tips
June is National Migraine Awareness Month, and we would like to recognize this by discussing a few current news articles and events surrounding migraines and how this misunderstood affliction affects our readers who suffer from migraines. Migraines are very common in the United States, with the World Health Organization estimating that 37 million people suffer from them. This includes 17 percent of women and 8 percent of men in the U.S. that experience some form of the condition. Caused by many different triggers, there is no singular definitive cause for migraines, but many studies and tests increasingly point to types of hyperactivity in the brain. New studies are beginning to shine some light on the causes of these debilitating headaches and how people can help mitigate the effects of migraines and continue to successfully contribute in their careers. Continue reading
Taking advantage of the resources on the Internet is a great way to stay “in the know” and help understand what is happening in your disability claim. Whether you are an insured or an agent, the insurance companies try to use the claims process to their advantage by frequently tweaking policy interpretations and creating unnecessarily complex procedures and processes as hoops to jump through to obtain disability benefits.
Here are a few resources that are useful to help comprehend what you’re up against in the claim process and provide some information on different types of disability coverages:
- Insurance Consumers – Disability Insurance: This website is a great overview of disability insurance, from obtaining a policy, to filing a claim, to understanding the claim examination process. It’s a great starting point for understanding disability insurance.
- Social Security Disability Resource Center: While our firm does not normally handle Social Security claims, many of our clients are required by their insurance company to also file for Social Security disability benefits. This resource has proven useful for people to understand that separate process.
- “Trust Law as Regulatory Law: The UNUM/Provident Scandal and Judicial Review of Benefit Denials under ERISA,” by John H. Langbein, Professor, Yale Law School: If you have the time, this is a very interesting (but long) legal academic study on the UNUM controversy from a few years ago. A very informative and eye-opening article on bad faith practices in the insurance claims industry.
- LifeHealthPro – Disability: This is an up-to-date listing of current events and news articles about disability insurance, Social Security, and other aspects of the disability world. It is a good resource for current issues in the industry and to keep track of new developments.
- Insurance Forums: This forum is a great place for agents and consumers alike to ask questions and find information on a range of different disability insurance policies and companies.
These are just a few of the many resources available on the Internet to help you better understand disability insurance and the disability claim process. Knowing more will help you take ownership of your disability claim and give you a fighting chance with the insurance company claim department instead of going to them, blindly assuming that they’ll pay you fairly, accurately, and timely.
Realizing the underlying reasons for the actions of the insurance company along knowing and exercising your rights are vital to a successful disability insurance claim. If you would like to share any other good resources or want to comment on the sites provided here, please do so in the comments section!
As always, you may visit our website or call us at 855.828.4100 for more information on how our firm can help you!