Short and long term disability coverage can vary quite significantly, and in fact, often differ to such a degree that insured disability claimants who qualify for benefits under one plan may be denied benefits under another plan.
Disability policyholders may be confused or even surprised by the possibility that their claim will “fall through the cracks,” so to speak. After all — to the average person — if one is severely injured or suffering from a condition that seriously impacts their ability to work, then their qualification for disability benefits seems obvious.
Insurers frequently take advantage of the fact that disability policyholders might not fully understand their policies, and that, as a general rule, disabling conditions put the claimant in a vulnerable position — when the policyholder has been disabled, they are likely more concerned with their recovery (and with integrating themselves into their normal life) than with the administrative hassle of securing benefits. Insurers understand this natural tendency and are more likely to deny or delay the processing of a legitimate disability insurance claim so as to discourage the policyholder from taking steps to obtain their rightful benefits.
At Bryant Legal Group, P.C., we encourage those who are involved in a dispute with their insurer to get in touch as soon as possible. Our experienced Chicago disability attorneys can assist you in bringing a dispute against the insurer to secure the benefits that you’re owed.
Automatic Qualification for Disability Benefits
Disability insurance carriers generally look for ways to exclude your condition from qualifying as a disability or to otherwise minimize your benefits entitlement. In rare cases, however, you can avoid the complicated calculus that surrounds the typical disability determination — more specifically, if your disability insurance policy includes a list of conditions that automatically qualify as a “disability.”
What conditions qualify automatically as a disability? In private insurance policies, the language and terms of the insurance contract can vary wildly — you’ll, therefore, want to evaluate the specifics of your insurance contract itself with the aid of an experienced Chicago disability attorney.
Still, despite the fact that insurance policies are quite variable when it comes to defining what constitutes a disabling condition, there are some commonalities that you might encounter. In the automatic qualification context, the following conditions are often listed in insurance policies as “disabling” (without further need to demonstrate the extent, nature, or impact of the impairment):
- Total blindness
- Total deafness
- Amputation of limbs
If you are suffering from a condition that qualifies automatically as a disability under your insurance plan, it’s important to note that you may still find yourself at the center of a dispute with your insurer — after all, the insurer may argue that your condition is “not quite” the same as the one that would automatically qualify for disability benefits.
For example, if you are suffering from hearing loss, the insurer may argue that it is not “total hearing loss” and as a result, insufficient to qualify for automatic disability benefits. In such cases, you can introduce supportive medical record evidence and the testimony of treating healthcare professionals.
Disability Coverage Varies Depending on the Language of the Insurance Policy
If you do not qualify for disability benefits automatically, then your condition will be evaluated pursuant to the disability definition established in the insurance contract itself. Policies vary considerably, but the disability definition issue is generally split along one major fault line: own occupation and any occupation.
Disability insurance policies which feature an “own occupation” definition of disability requires that the claimant demonstrate that their particular injury, illness, or condition renders them incapable of performing the duties of their own occupation. For example, if you are a lawyer for a large law firm, then your neurological condition may make it impossible for you to work in your own occupation and you should be entitled to benefits under your individual disability policy. The “own occupation” definition is less strict than the alternative “any occupation” definition.
Disability insurance policies that feature an “any occupation” definition of disability requires that the claimant demonstrate that their particular injury, illness, or condition renders them incapable of performing any job duties, for any alternative occupation that they would otherwise be qualified to handle. For instance, if you are a dentist, but you have some experience doing administrative work, then your spinal condition may make your current occupation impossible, but may still allow you to take on office work. Under an “any occupation” of disability, you may not be entitled to benefits.
Importantly, the “any occupation” definition does not require you to show that you cannot perform any job on the market — usually, only those that you would be qualified to work. If you do not have a college degree, for example, the insurer cannot reasonably argue that you could find alternative work as a management consultant.
Mental Health Conditions
Remember, plans vary. Mental health conditions are generally covered by most long-term disability policies, though limitations are often in place to prevent lifetime recovery — for example, the “mental or nervous condition” limitation may prevent you from obtaining benefits for more than two or three years. Contact our Chicago disability attorneys if you have questions or concern in this regard.
Vocational Expert Testimony
Questions concerning the nature of your occupation (or that of alternative occupations that you might be capable of engaging) lie at the very foundation of a typical private disability benefits dispute. Vocational analysis is therefore critical to success in securing the benefits that you’re owed. Our attorneys have extensive experience working with vocational opinions and vocational experts; we understand the tools that they use and how to frame arguments of medical restrictions and limitations in vocational terms.
If a vocational expert convincingly opines that the limitations imposed by your condition are not “disabling” in the sense that they do not impact your ability to perform the primary functions of your current occupation, then that could completely undermine your argument for disability benefits. On the other hand, if you introduce a vocational expert who clearly describes how the deficits/impairments at-issue would prevent you from working in your own occupation (or perhaps, depending on the language of your policy, from working in any alternative occupation), then that could strengthen your claim substantially.
Vocational experts cannot opine as to the specifics of your disabling condition, as they are not qualified to do so. Instead, they will testify as to how the asserted impairments — physical and/or mental — will influence your ability to do your job. The vocational expert is therefore qualified to speak about your career and your industry at-large, as well as how your background (training, education, skillset, etc.) plays into your candidacy.
For example, if you are an anesthesiologist whose spine has been severely damaged due to a degenerative condition, a vocational expert would be able to determine whether you have the training, skillset, and physical ability to perform some other less-demanding occupation.
Though vocational experts are only qualified to speak about career issues and prospects, they may make mistaken assumptions about certain aspects of your disability, which can influence their recommendations and overall testimony.
For example, if a vocational expert misunderstands your spinal condition and assumes that you are capable of sitting down for lengthy periods of time (when, in fact, you are incapable of sitting or standing for more than an hour or two at a time), then that is likely to influence their evaluation of your job prospects. Our Chicago disability attorneys can challenge their opinions by presenting additional evidence clarifying the limitations imposed by your condition.
Residual Benefits May Be Available
Depending on your private disability insurance plan, you may qualify for residual benefits, even if you are not entitled to obtain full disability benefits. Residual benefits are a form of partial income replacement in situations where your disabling condition may impact your ability to work, but not to the degree necessary to qualify for full benefits — for example, if you can still perform the general job duties required of you in your position of employment, but your effectiveness and efficiency has been seriously influenced by your condition (thus reducing your income), then you could ostensibly recover residual benefits to replace the lost income.
Residual benefits typically pay out a percentage of your total disability benefit, in proportion with the lost income, though the amount of income lost must be above a certain specified percentage (e.g. 20 or 25 percent for most plans).
Let’s use a quick example for clarity.
Suppose that you purchase an individual long-term disability plan which includes a total disability benefit of $4,000 per month. You are injured in a car accident, though your injuries are not so catastrophic that you qualify for full disability benefits under the plan definition. The impairments and deficits caused by your injuries have reduced your overall income by 25 percent, however. Given the circumstances, you would be entitled to 75 percent of your total disability benefit (i.e., $3,000 per month).
Generally speaking, residual benefits are long-term, and the length of the payout matches that of the underlying plan through which they are provided. If your long-term disability coverage lasts for a period of five years, then your residual benefits (governed by the same plan) are also likely to last for a period of five years. Although maximum benefits can differ between total and residual disability benefits, your specific policy includes the terms that will appy to your claim.
Contact Our Team of Skilled Chicago Disability Attorneys for Assistance With Your Dispute
If you are currently embroiled in a disability insurance dispute in which the insurer has wrongfully denied, delayed, or otherwise mishandled your benefits claim, then you may be entitled to the benefits owed, as well as additional damages (depending on the particular circumstances of your dispute). Whether you are moving through an internal appeals process with the insurer, or bringing a lawsuit against the insurer, effectively navigating the process can be quite a challenge. As such, we encourage you to contact a qualified attorney at Bryant Legal Group, P.C. for further guidance on how to proceed with your dispute.
Here at Bryant Legal Group, P.C., our attorneys have decades of experience representing insurance claimants in disputes with their insurers, including private disability insurance disputes.
We are committed to the provision of comprehensive legal assistance, and as such, we keep clients thoroughly apprised of developments in their case and work closely with clients to ensure that our strategic goals are aligned throughout the litigation process. When handling disability disputes, we engage with staff physicians to provide cutting-edge analysis of medical records and literature, giving us insight into the nature of the claimant’s condition and how best to present such information.
Our results speak volumes about the efficacy of our comprehensive approach to legal advocacy. Over the years, we have secured millions in benefits (and other damages) for our clients in negotiated settlements and trial verdicts.
Interested in learning more?
Call (312) 561-3010 or submit an online case evaluation form through our website to get connected to one of our experienced Chicago disability attorneys for assistance. We look forward to helping you with your insurance dispute.