Navigating an “Any Occupation” long term disability claim versus an "Own Occupation" claim can be an overwhelming and stressful experience. You may feel that you’ve provided ample evidence of your inability to work, yet your insurance company keeps requesting more and more. When filing for long term disability, it’s essential to understand the definition of disability you must meet, the documentation needed to support your claim for benefits, and how to avoid common mistakes in the claims process.
In this article, we’ll explain the meaning of an “Any Occupation” definition of disability in long term disability claims and share strategies you can utilize to increase your chances of a successful outcome.
What Does “Any Occupation” Mean in Long Term Disability Claims?
The term “Any Occupation” in long term disability insurance refers to the standard used by insurance companies to determine your eligibility for benefits. Under this standard, you must be unable to perform any job for which you are reasonably suited by education, experience, or training, not just the job you were performing at the time of your disability. This can include a wide range of jobs that you may not have considered, as long as they align with your skills and qualifications.
There are typically four types of definitions used in disability policies:
Any Occupation: You are considered disabled if you are unable to perform any job that fits your education, training, or experience. This is the strictest standard and often requires thorough evidence that you cannot perform any type of work.
Any Gainful Occupation: You are considered disabled if you are unable to perform any job that fits your education, training, or experience, and you are unable to earn at least a certain percentage of the income you were earning before your disability. Typically, you must be unable to earn 50% to 80% of your predisability income.
Own Occupation: You are considered disabled if you cannot perform the specific duties of your own job or occupation. This standard is more lenient, focusing solely on your ability to continue in your particular role.
Hybrid Definition: This starts with the “Own Occupation” standard for an initial period, usually around two years, and then shifts to the “Any Occupation” or "Any Gainful Occupation" standard. This means that initially, your claim is evaluated based on your ability to perform your specific job, but after the initial period, it is assessed based on your ability to perform any job suitable for you.
Understanding these definitions is crucial, as they significantly impact the evaluation of your disability claim and the benefits you may receive. Your policy documents will specify which definition applies to your claim, so reviewing these details carefully is important.
How Does “Any Occupation” Differ from “Own Occupation”?
The “Any Occupation” and “Own Occupation” standards represent two distinct approaches to evaluating disability claims. The primary difference lies in the scope of work you are expected to perform despite your disability.
Any Occupation: Under this standard, you are considered disabled only if you are unable to perform any job that suits your education, experience, and training. This means that even if you cannot perform your previous job, you must also be unable to perform other types of work that you are qualified for. This standard is stricter and more comprehensive, as it requires proving that your condition and symptoms prevent you from working in any capacity that fits your background.
Own Occupation: This standard is more specific and focuses solely on your ability to perform the duties of your own job or occupation. You are considered disabled if your condition prevents you from carrying out the tasks associated with your specific role, regardless of whether you could potentially perform other jobs. This is a more lenient standard because it does not require you to be incapable of all work, just the work you were doing prior to your disability.
In evaluating disability claims, insurance companies use these standards to determine your eligibility for benefits. With the “Own Occupation” standard, you may qualify for benefits if you can no longer perform the specific tasks of your job, even if you can do other types of work. Conversely, under the “Any Occupation” standard, you must demonstrate that your disability is so severe that you cannot perform any job for which you are reasonably qualified. Understanding which standard applies to your policy is essential, as it affects the proof and documentation you will need to support your claim.
What Factors Are Considered in an “Any Occupation” Review?
When insurance companies conduct an “Any Occupation” or "Any Gainful Occupation" review, they evaluate several key factors to determine whether you are capable of performing any job for which you are reasonably suited. These factors include:
Physical Capabilities: Your physical abilities and limitations are thoroughly assessed. This includes evaluating your capacity to perform tasks such as lifting, standing, walking, and other physical activities that may be required in various jobs. Medical records, physician statements, and functional capacity evaluations are often used to determine your physical capabilities.
Cognitive Capabilities: Your cognitive and psychological health is also examined. Insurance companies will consider your ability to concentrate, remember, make decisions, and handle work-related stress. Neuropsychological evaluations and records from psychologists or psychiatrists may be reviewed to assess these aspects.
Work Experience: Your prior job experience and the skills you have acquired are taken into account. This helps determine the types of jobs you might be qualified for based on your professional background. A detailed work history can provide insight into the range of roles you could potentially perform.
Education and Training: The level of education and any specialized training you have received are important factors. Higher education and specialized training can qualify you for a wider variety of jobs, which the insurance company will consider when evaluating your ability to work.
Transferable Skills: Insurance companies look at skills that can be transferred from your previous job to other types of employment. For instance, if you have strong organizational or managerial skills, these could be applicable in different occupations even if your physical limitations prevent you from performing your previous job.
Vocational Assessments: Vocational experts may be brought in to assess your employability. They consider your physical and cognitive capabilities, work experience, education, and transferable skills to determine what types of jobs you could reasonably perform.
Earnings Potential: If the operable definition is "any gainful occupation," vocational experts may also assess the earnings potential of any jobs you could reasonably perform. Again, the earnings potential must be below the threshold specified in the definition - typically 50% to 80% of your prior predisability income.
Labor Market Conditions: The availability of suitable jobs in the current labor market is also considered. If there are few or no job opportunities that match your qualifications and limitations, this can impact the determination of your ability to work.
During an “Any Occupation” review, your insurance company will compile and analyze all these factors to make an informed decision about your claim. Providing comprehensive and accurate documentation for each of these areas can significantly impact the outcome of your disability claim.
What Evidence Is Needed to Support Your “Any Occupation” Claim?
Supporting a claim under the “Any Occupation” standard requires comprehensive evidence demonstrating that you are unable to perform any job for which you are reasonably suited.
The following types of evidence are crucial in building a strong claim for benefits:
Medical Records: Detailed medical records are essential in documenting your condition, treatments, and the progression of your disability. These records should include information from all healthcare providers involved in your care, such as doctors, specialists, and therapists. Consistent and thorough documentation of your symptoms, diagnoses, and treatments helps establish the severity and impact of your disability.
Doctors’ Opinions: Statements and evaluations from your treating physicians carry significant weight. It is important to pay special attention to an attending physician's statement. These opinion letters and statements should clearly articulate your physical and mental limitations and explain how these limitations prevent you from performing any job. It’s important that your doctors provide detailed descriptions of your functional impairments and how they affect your ability to work.
Functional Capacity Evaluation (“FCE”): A functional capacity evaluation is a comprehensive assessment performed by a physical therapist or occupational therapist that measures your physical abilities and limitations. This evaluation provides objective evidence of your capacity to perform work-related tasks, such as lifting, carrying, sitting, standing, and walking.
Cognitive and Mental Health Evaluations: If your disability includes cognitive or psychological impairments, evaluations from psychologists or psychiatrists are crucial. These assessments should detail your mental health condition, cognitive limitations, and the impact of these factors on your ability to work in any capacity. Additionally, a neuropsychological evaluation can provide in-depth and objective evidence of your cognitive impairments.
Vocational Assessments: Vocational experts can provide valuable insight into your employability. These assessments consider your physical and cognitive limitations, work history, education, and transferable skills to determine whether there are any jobs you can reasonably perform. Vocational reports can support your claim by demonstrating that your disability precludes you from all suitable employment opportunities.
Personal Statements: Your own testimony about your condition and how it affects your daily life and ability to work can be persuasive. Detailed descriptions of your symptoms, daily challenges, and the ways in which your disability limits your functional capacity can provide a personal perspective that complements medical and vocational evidence.
Third-Party Statements: Statements from family members, friends, or former colleagues who can attest to the impact of your disability on your ability to work can also be helpful. These third-party observations can corroborate your own accounts and provide additional context.
Gathering and presenting comprehensive evidence in these areas is critical to supporting your “Any Occupation” claim. Consider consulting an experienced long term disability attorney who can assist in working closely with your healthcare providers, obtaining thorough evaluations, and compiling detailed documentation to strengthen your case and increase the likelihood of a favorable outcome.
What Common Reasons Do Insurance Companies Use to Deny “Any Occupation” Claims?
Insurance companies often deny “Any Occupation” claims for various reasons, typically focusing on perceived gaps or inconsistencies in the evidence provided. Understanding these common reasons can help you prepare a stronger case.
Common reasons used by insurance companies include:
Insufficient Medical Evidence: One of the most common reasons for denial is the lack of sufficient medical documentation to support the claim. Your insurance company may argue that the medical records do not demonstrate a level of disability severe enough to prevent you from performing any job. Ensuring your medical records are thorough and up-to-date is crucial.
Inconsistent Medical Opinions: Discrepancies between different medical providers’ opinions can lead to a denial. If your doctors’ assessments of your condition and limitations vary significantly, the insurance company may use this inconsistency to question the validity of your claim. Coordinating with your healthcare providers to present a consistent narrative is important.
Failure to Meet Policy Definitions: Insurance companies may argue that your condition does not meet the specific definitions of disability outlined in your policy. This can include not fitting the criteria for “Any Occupation” due to the nature of your limitations. Understanding your policy’s definitions and ensuring your evidence aligns with them is essential.
Lack of Objective Evidence: Insurance companies often require objective evidence of disability, such as diagnostic test results or Functional Capacity Evaluations. Disability claims based heavily on subjective symptoms without corroborating objective evidence may be denied. Including objective medical tests and evaluations can strengthen your claim.
Vocational Evidence Contradictions: Vocational assessments may conclude that you can perform certain types of work despite your limitations. If your insurance company’s vocational expert determines there are jobs you can do, this can be grounds for denial. Countering this with comprehensive vocational evaluations from your own experts is necessary.
Improvement in Condition: If there is evidence suggesting that your condition has improved over time, the insurance company may argue that you are no longer disabled under the “Any Occupation” standard. Regularly updating your medical records to reflect the current state of your condition can address this issue.
Non-Compliance with Treatment: Failing to follow prescribed treatments or therapies can be used as a reason for denial. Your insurance company may argue that your condition could improve with proper treatment, and thus you could return to work. Adhering to your treatment plan and documenting your compliance is important.
Surveillance and Social Media: Insurance companies sometimes use surveillance or social media activity to gather evidence that contradicts your claim. If they find activities that appear inconsistent with your reported limitations, they may use this as grounds for denial. Being mindful of your activities and social media presence can help avoid this issue.
Understanding these common reasons for denial can help you anticipate potential challenges and proactively address them in your claim. Providing comprehensive, consistent, and objective evidence, and understanding your policy’s specific requirements are key steps in successfully navigating an “Any Occupation” disability claim.
What Should I Do If My Long Term Disability Claim Is Denied Under the “Any Occupation” Standard?
Facing a denial of your long term disability claim under the “Any Occupation” standard can be disheartening, but it’s important to remember that this is not the end of the road. There are several steps you can take to appeal the decision and strengthen your case.
Here are steps you can take to help you navigate this challenging process:
Carefully Review the Denial Letter from Your Insurance Company: This letter should outline the specific reasons for the denial and provide details on how to appeal the decision. Understanding why your claim was denied is crucial for addressing any deficiencies in your original application.
Gather Additional Evidence: Collect updated medical records, new opinions from your treating physicians, and additional objective testing such as a neuropsychological evaluation or Functional Capacity Evaluation. Ensure that all documentation is thorough and clearly demonstrates how your condition prevents you from performing any job for which you are reasonably suited. Additionally, vocational experts can provide assessments that support your inability to work in any occupation, offering a detailed analysis of how your condition limits your employability.
Consult with an Long Term Disability Attorney: Consider retaining a long term disability attorney who specializes in ERISA (“Employee Retirement Income Security Act”) and long term disability claims. An long term disability attorney can help you understand the legal aspects of your claim, ensure all necessary evidence is collected, and represent you in communications with the insurance company.
Prepare a Formal Appeal: The long term disability appeals process typically involves submitting a formal appeal to the insurance company, which may include additional documentation and a detailed explanation of why the denial was incorrect. Be mindful of any deadlines, as missing these can jeopardize your appeal. Your attorney can assist in preparing a compelling appeal package that addresses your insurance company’s reasons for denial and provides robust evidence to support your claim.
Escalate if Necessary: If your initial appeal is denied, don’t lose hope. Some insurance policies offer multiple levels of appeal, and you most likely have the right to file a lawsuit if necessary. Throughout this process, maintaining clear and consistent communication with your healthcare providers, keeping detailed records of all interactions with your insurance company, and ensuring all submissions are timely and complete can significantly enhance your chances of overturning the denial.
By taking these steps—gathering additional evidence, consulting with a long term disability attorney, and navigating the appeals process diligently—you can effectively challenge the denial of your long term disability claim under the “Any Occupation” or "Any Gainful Occupation" standard and work towards securing the benefits you deserve.
How Can The Maddox Firm Prove My Long Term Disability Claim?
The Maddox Firm is dedicated to helping you secure the long term disability benefits you deserve. Our experienced team will work tirelessly to prove your claim and ensure you receive the support you need.
Here are a few ways we can assist you throughout this process:
We Examine Your Policy and Assess Your Claim: We start by thoroughly reviewing your long term disability policy to understand the specific terms, conditions, and definitions that apply to your claim. This helps us assess the strengths and weaknesses of your case and develop a strategic approach to maximize your chances of success.
We Handle All Communications with Your Insurance Company: Dealing with insurance companies can be stressful and overwhelming. We take over all communications on your behalf, ensuring that every interaction is handled professionally and effectively. This includes submitting necessary documentation, responding to inquiries, and negotiating with your insurance company to advocate for your best interests.
We Help You Obtain Evidence to Support Your Claim: Gathering comprehensive evidence is crucial to proving your disability claim, especially under an “Any Occupation” review. We assist you in obtaining all necessary documentation, including medical records, doctor’s opinions, neuropsychological evaluations, Functional Capacity Evaluations, and vocational assessments. Our team ensures that all evidence is thoroughly documented and clearly demonstrates your inability to perform any occupation.
We Handle Appeals and Litigation: If your claim is denied, we guide you through the appeals process, preparing a strong appeal package that addresses the reasons for denial and provides additional evidence to support your claim. If necessary, we are prepared to take your case to court, representing you in litigation to fight for the benefits you deserve.
By leveraging our expertise and dedication, The Maddox Firm can effectively prove your long term disability claim and help you secure the benefits you need to support your well-being and financial stability.
Continuing a long term disability claim into the any occupation period can be a complicated process. If you need help during the claims process, with appealing a claim denial, or with litigating a final adverse short term or long term disability decision, The Maddox Firm can help. The experienced team at The Maddox Firm will examine your insurance policy, correspondence from your insurance company, medical records, and any other relevant documentation in order to give you personalized guidance on how we can help you win your short and/or long term disability claim. Our New Jersey and New York long term disability attorneys help clients nationwide.