When you suffer a condition that leaves you unable to work, you may qualify to receive 50 to 80 percent of your pre-disability income on a monthly basis. What you believe qualifies you for total disability payments and what your insurer actually thinks can be two completely different things, however. Here's how insurers typically define total disability and what you can do to ensure you meet those definitions and avoid having your benefits reduced or your claim denied altogether.
Total Disability Defined in Two Ways
Total disability is defined as the inability to perform the primary aspects of your job. If your primary duty is to type reports but you can't use your hands due to severe carpal tunnel, you would likely qualify for benefits. However, your claim approval will often hinge on whether your disability makes it impossible for you to work any job or just jobs in your field.
This is because disability insurance policies usually have either an "own occupation" or "any occupation" clauses. With an "own occupation" clause, the insurance company will consider you to be totally disabled if you cannot perform any job in a profession you trained and/or were educated for. If you were a surgeon and you were unable to perform procedures because you couldn't stand for long periods of time anymore, your insurance provider would consider you totally disabled even though you may be able to work in a different field.
With "any occupation", on the other hand, you're only considered totally disabled if you could not work anywhere due to your condition. If you could still obtain gainful employment in another area, the insurance company may only consider you to be partially disabled and give you less money than you would've received if you'd been found totally disabled.
Your insurance policy will detail which of these standards your claim will be held to. Be aware, some disability insurance policies will employ both standards. The company will use the "own occupation" standard when you first get the insurance and the switch to "any occupation" after a period of time (e.g. 2 years). It's important to carefully read your policy to determine how your claim will be judged.
Avoiding a Denial of or Reduction in Benefits
Insurance companies don't like paying benefits. Therefore, they will look for any opportunity to pay you less than you deserve or deny your claim altogether. One trick they like to pull is to do a line-by-line evaluation of policyholders' job descriptions and approve/disapprove benefits based on whether or not they think the individuals are really unable to perform those tasks.
For instance, if you can't type because of severe carpal tunnel, the insurance company may claim you can still do the work if you use an assistive device, such as voice recognition software. The company may ignore the fact that you would still be required to do some typing to correct any mistakes as well as overlook any other medical restrictions you have.
Another trick insurance companies like to pull is to dispute that certain duties are a material aspect of the job. Even though typing is 80 percent of the work you do, the company may claim it's not as important as other tasks you must perform in the position, for example.
The best way to push back against both of these tricks is to develop a detailed description of your occupational duties, categorize them, and estimate the amount of time you spend doing each one. You should then demonstrate how your disability prevents you from adequately performing those duties.
To counter any claims of illegitimacy, be sure to have the job description certified by your employer and have your doctor follow up with notes on how your restrictions impact your ability to continue working in your occupation.
To learn more about this issue or help litigating a disability claim, contact an attorney at a place like Iler and Iler.