Most group disability insurance policies define “disability” as the inability of the insured to perform the duties of their regular occupation on account of sickness or injury. However, that standard typically applies only for the first 24 months the insured is eligible to receive benefits. After 24 months, most policies require that the insured must be unable to perform “any occupation” to continue receiving benefits beyond the initial 24-month period. But what does “any occupation” mean?
Related Article: The Vocational Aspects of Disability Insurance Benefit ClaimsTable of Contents
The Wording of the Policy Is Critical
In general, the “any occupation” definition of disability found in group disability insurance policies is more liberal than the definition of “disability” under the Social Security Act. To qualify for Social Security disability insurance benefits, a claimant must establish their inability to engage in “any substantial gainful activity” according to Section 205 of the Social Security Act. This means the ability to perform any work for pay, no matter how menial, generally precludes an award of benefits from the Social Security Administration.
Disability insurance policies often contain a definition of “any occupation” that is not as draconian. Instead, the policies specify that “any occupation” needs to be an occupation the insured is fitted to perform by reason of training, education, and experience. However, some policies state that “any occupation” is one the insured may become qualified to perform. Such language means that if the insured can receive training or education to perform a job, they may not qualify for “any occupation” disability benefits. So long as existing vocational skills are transferable to another occupation, a disability insurance claimant may be found disqualified from receiving benefits by the disability insurer.
Other policies explicitly contain an earnings requirement. Thus, even if an insured may not qualify for Social Security disability benefits, their inability to be able to perform a job that pays a wage comparable to prior earnings would meet the “any occupation” definition of disability.
Even if such language is not explicitly included by disability insurers in their policies, it may be implied. Numerous legal precedents have found that “any occupation” requires that the claimant be capable of performing an occupation in their “station in life.” So, an executive or professional would not be ineligible to receive benefits if they could perform a minimum-wage job. A federal appellate court ruling from the 1980’s, Helms v. Monsanto is such an example. The court found that an insured’s inability to earn “a reasonably substantial income rising to the dignity of an income or livelihood, even though the income is not as much as he earned before the disability,” entitles the insured to benefits.
What Evidence Does an Insured Need to Prove the Inability to Perform the Duties of “Any Occupation?”
First, an award of Social Security disability benefits is often enough to show that the insured meets the “any occupation” definition of disability. However, that is not always the case since Social Security takes into consideration factors such as a claimant’s age. SSA also utilizes rules specific to the Social Security disability program to determine eligibility. Disability insurers may assert they are not required to follow Social Security’s requirements.
A potential solution is for someone who has been awarded Social Security Disability Insurance Benefits to obtain a copy of their Social Security claim file, inclusive of a document entitled, “Disability Determination Explanation.” That document is an internal memo prepared by SSA that includes a flow chart analysis of a disability claim and lists the evidence considered medical issues, and vocational considerations. The analysis may show the claimant is unable to perform any occupation irrespective of any consideration of rules unique to the Social Security Administration.
In the absence of a Social Security determination, claimants need to collect evidence from their doctors about their limitations and the impact of their symptoms and functionality on their ability to work – both physically and cognitively/mentally. It is never enough to just rely on a conclusory statement from a doctor stating their patient “cannot work.” Instead, the doctor must provide specific limitations such as how long their patient can sit, how long they can stand, how far they can walk, and how much weight they can lift and carry. Likewise, if there are cognitive or psychiatric limitations, such as difficulty reading, remembering, or paying attention, the treating doctor should indicate those limitations.
It may also be necessary to obtain input from a vocational rehabilitation consultant. Such individuals have training in analyzing medical records and jobs and can report that even if a claimant could work, they could only do so at a job that pays a negligible salary in comparison to their prior occupation.
Related Article: Clarifying Occupation in Disability Insurance: A Guide to Navigating Your ClaimWhen Should a Claimant Seek Legal Assistance?
If the insurance company is questioning whether a disability benefit recipient would meet the “any occupation” definition of disability, it may be prudent to seek legal advice right away. In any event, if the disability insurer determines the claimant can perform “any occupation,” legal assistance with an appeal is essential. Claimants should look for an attorney experienced in handling disability insurance claims and who possess the expertise and resources to draw upon.
Claimants need to appreciate that the ability to perform “any occupation” is a vocational determination, and doctors lack the expertise or qualifications to offer vocational opinions. An “any occupation” determination is based on a variety of factors, such as a claimant’s training, education, and experience. Additionally, it includes consideration of medical factors that go beyond a diagnosis and address the physical and mental impact of the claimant’s medical condition or conditions. Insurers usually rely on their own vocational rehabilitation consultants, which makes it incumbent on claimants to retain their own vocational consultant to present a response.
Meet Our Experienced Attorneys
The lawyers at DeBofsky Law have decades of experience in assisting disability benefit claimants in proving they meet the policy requirements necessary to continue receiving benefits. That experience is backed up by their track record of success with insurance companies and in court.
