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Attorney Explains Difference between Definition of Disability

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Minneapolis, MNChances are, if you are asked to define disability, it won’t be the same definition as written in your disability insurance policy. Attorney Kristen Gyolai with Fields Law Firm wants you to know that there is a discrepancy between policy holders and how that policy defines disability.

Gyolai says the most important component to take into consideration when applying for long term disability (LTD) benefits is the “material and substantial duties” or your regular occupation. “The insurer means those duties that cannot be omitted from your job,” she explains. “For instance, a welder can’t climb up and down ladders due to his disability but that isn’t a material and substantial duty of being a welder. However, it is a big part. The insurer can tell the welder that they can still weld and you aren’t disabled.” But the problem for the welder is finding a job where he doesn’t need to climb the ladder.

There is a second component that most people don’t understand until they have an attorney explain. “So many LTD policies state that, during the initial 24- month period you have to be disabled from your regular occupation, but after that time the definition of disabled can change,” says Gyolai. What was once “own occupation” morphs into “any occupation”. And this means that an attorney doesn’t have to prove that their client is disabled from the time they became disabled. “Instead, I must prove there are no jobs they can perform,” she explains. That change in the definition of disability is usually a trigger (or a point in time) for the insurance company to deny benefits.

Policy holders typically don’t know there are two different definitions of disability they would eventually have to meet after 24 months collecting LTD. Your policy states that ‘after 24 months you must be unable to perform the duties of ANY occupation”, or words to that effect. “I think generally policy holders don’t read their policy. They assume if they cannot work they will get disability benefits,” says Gyolai.

According to the Americans with Disabilities Act (ADA), a disabled person is an individual “who has a physical or mental impairment that substantially limits one or more major life activity. And the US Department of Labor defines disability as “someone who has a physical or mental impairment that substantially limits one or more ‘major life activities’, has a record of such an impairment, or is regarded as having such an impairment.”

The medical definition of disability is “the impact of impairment on a person's ability to meet the demands of his or her life”. And then there is the insurance company’s definition of disability, which includes “own occupation” and the more restrictive “any occupation” definition. For example, in the lawsuit Frankton v. Metropolitan Life Insurance Company, according to Metropolitan Life, Disability or Disabled means that, due to an Injury or Sickness, you require the regular care and attendance of a Doctor and:
1. you are unable to perform each of the material duties of your regular job, as set forth in the Employee's job description that is maintained by the Employer; and
2. after the first 24 months of Monthly Benefit payments, you must also be unable to perform each of the material duties of any occupation for which you are reasonably or may reasonably become qualified taking into consideration your prior training or training available through a rehabilitation program offered to you and approved by us, your education, your experience and your past earnings.”

This means that, according to the insurance policy, the definition of disability narrows after 24 months of benefit payments. After 24 months of benefit payments, determination of whether a claimant is disabled shifts from an evaluation of the claimant's "regular job" to an evaluation of "any occupation”. In the above case, MetLife requested that Plaintiff provide it with pharmacy records, medical records, and an additional Attending Physician Statement that focused on her functional capabilities. MetLife reviewed the additional documentation provided by Plaintiff and concluded that she should undergo an independent medical examination. Six months after granting Plaintiff's appeal, MetLife requested additional documentation from Plaintiff to evaluate whether she continued to qualify for benefits. The plaintiff was denied further benefits.

So be aware of how your insurance policy defines disability.


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