Under the terms of a typical Long Term Disability Plan (hereinafter “Plan”), you are entitled to long-term disability (“LTD”) benefits when the insurance company “determines” that:
- you are unable to perform the material and substantial duties of your regular occupation due to your sickness or injury; and
- you have a 20% or more loss in your indexed monthly earnings due to that sickness or injury.
After 24 months of payments, you are considered disabled under the terms of the Plan when the insurance company determines that, due to the same sickness or injury, you are unable to perform the duties of any gainful occupation for which you are reasonably fitted by education, training or experience.
The loss of a professional or occupational license or certification does not, in itself, constitute disability.
The insurance company may require you to be examined by doctors, other medical practitioners or vocational experts of the insurance company’s choice. The insurance company will pay for these examinations. The insurance company can require examinations as often as it is reasonable to do so. The insurance company may also require you to be interviewed by an authorized representative of the insurance company. Refusal to be examined or interviewed may result in denial or termination of your claim.
Material and substantial duties means duties that:
- are normally required for the performance of your regular occupation; and
- cannot be reasonably omitted or modified … .
Regular occupation means the occupation you are routinely performing when your disability begins. The insurance company will look at your occupation as it is normally performed instead of how the work tasks are performed for a specific employer or at a specific location.
Gainful occupation means an occupation, including self employment, that is or can be expected to provide you with an income equal to at least 60% of your indexed monthly earnings within 12 months of your return to work.
A typical Plan will further provide terms and conditions similar to the following:
What Disabilities Have a Limited Pay Period Under Your Plan?
Disabilities due to a sickness or injury which, as determined by the insurance carrier, are primarily based on self-reported symptoms have a limited pay period during your lifetime.
Disabilities which, as determined by the insurance carrier, are due in whole or part to mental illness also have a limited pay period during your lifetime.
The limited pay period for self-reported symptoms and mental illness combined is 24 months during your lifetime.
Self-reported symptoms means the manifestations of your condition, which you tell your doctor, that are not verifiable using tests, procedures and clinical examinations standardly accepted in the practice of medicine. Examples of self-reported symptoms include, but are not limited to headache, pain, fatigue, stiffness, soreness, ringing in ears, dizziness, numbness, and loss of energy.
Mental illness means a psychiatric or psychological condition regardless of cause. Mental illness includes but is not limited to schizophrenia, depression, manic depressive or bipolar illness, anxiety, somatization, substance-related disorders and/or adjustment disorders or other conditions.