Question: I have been on long term disability benefits for the past 20 months. I recently received information from the insurance company regarding a “change in the definition” of disability and an “any occupation” review. What does this mean?
Answer: This means that your disability claim is about to go through a process to prove once again that you are disabled essentially, but this time, you will have to prove that you cannot work in “any occupation” not just your “own occupation.”
Let’s break this down a little further.
If you were working as an auto mechanic, that is considered your own occupation. If you injure your back, then you may not be able to work as a mechanic any longer because you can no longer do the essential duties of that job like bending, reaching, pulling, pushing, and using your back muscles in the way that is necessary to work on cars.
But during a claim review under the “any occupation” standard (typically after two years of being on LTD), the insurance company will look to see if you can work any occupation. “Any occupation” could be working as a salesman or secretary in the auto body shop instead of a mechanic. Or it could mean working in another field of work altogether.
The 24-Month Rule
Most disability policies cover you under your own occupation for the first 24 months. Around that 24 month mark, you will start receiving documents that explain your claim is about to go into the review process for any occupation. The insurance company will hire vocational experts to investigate your level of skill, experience, and education to find a job that would be a suitable replacement occupation. This will cause your claim to be dismissed.
The Transition Process from Own to Any Occupation
Step #1 Vocational Expert Begins Research
As the 24-month date approaches for a claim, the insurance company will provide a vocational expert with a copy of your file to use in their investigation of extending your claim. A vocational expert is a person hired by both the insurance company and disability attorneys as a neutral person who has experience in job placement, earnings histories, employment history, and opportunities.
Step #2 Transferable Skills Analysis
After the initial research, the vocational experts will use software programs to determine your transferable skills called a Transferable Skills Analysis (TSA). The TSA will determine what jobs you could work, based on your education and income levels as well as your disability diagnosis. The most important part of this process is to determine if you have a “sedentary capacity to work”. In other words, could you work a job that requires little physical labor except for sitting and performing office duties?
Step #3 Vocational Report
The vocational expert will put together a report that will outline whether or not you can work in a sedentary position. This is the most important information that will affect your claim. If you are found to be able to work in a sedentary position, the vocational expert will also provide a list of jobs that you are qualified to work, resulting in the insurance company canceling your claim. If you are found to be unable to work a sedentary job, your claim will be approved and expected to be paid out until your policy ends or you turn 65 years old.
It’s important to note that most claims are dismissed at the 24-month mark based on the vocational expert’s report. If you have a degenerative disease that will only continue to get worse, it’s worth fighting the insurance company for extended coverage until your policy runs out. Vocational experts have a vested interest finding you able to work as it is highly unlikely the insurance company will continue to hire them if they find a large number of claimants unable to work.
Sneaky Insurance Tactics
In 2016, the ERISA insurance disability benefits laws were updated. This prohibited the use of incentives for claims adjusters, investigators, and doctors to deny claims. However, the insurance companies can still use their discretion when it comes to extending contracts to people they know are more likely to side with them over the claimants.
Claims adjusters have also been known to not put all the information into the claimant’s file, whether accidentally, due to case manager changeovers, or intentionally. They have also been known for not providing the vocational expert with the complete list of restrictions and limitations imposed by the doctors of claimants. This can cause the vocational experts’ reports to be faulty.
The best way to fight the insurance company for a claim is to use an experienced long term disability attorney. The Ortiz Law firm knows all about the insurance companies’ sneaky tactics to cancel claims. They can help you gather your documents, review your claim, and even hire vocational experts to speak on your behalf. Call them for a free, no-obligation consultation today at (888) 321-8131.