Important Definitions and Long Term Disability

When applying for your long term disability benefits it is important to understand your rights. Each party is governed by the specific contract terms of the policy. Your rights are covered by the insurance contract and the insurance companies responsibilities are also covered by the same contract terms.

What is a pre-existing condition?

This is usually defined as any medical condition for which you have received “medical care” three or more months prior to the effective date of insurance coverage. Medical care includes the use of prescription drugs and physician consultations and services. Disability plans usually exclude or limit coverage for that medical condition for a specified time period.

What are some typical definitions of “own occupation” disability?

“You are considered totally disabled if, due to sickness or accidental bodily injury, you are unable to perform the material and substantial duties of your occupation.”

“The inability to perform the material and substantial duties of your regular occupation, the insurance company will consider your occupation to be the occupation you are engaged in at the time you become disabled, they will pay the claim even if you are working in some other capacity.”

What is a “modified own occupation” definition of disability?

“You are totally disabled, if solely due to sickness or injury, you cannot perform the material and substantial duties of your regular occupation and you are not working in any gainful occupation.” This definition is typically used to reduce benefit payments to someone who is disabled from their occupation but chooses to work in another occupation.

What are some typical definitions of “any occupation” disability?

“You are considered totally disabled if you are unable to perform the material and substantial duties of any occupation for which you are reasonably fitted by education, training, or experience.”

“Because of sickness or injury you are unable to perform the material and substantial duties of your occupation, and are not engaged in any other occupation.”

“A total disability, which is a medically determinable physical or mental impairment which renders the Participant incapable of engaging in any substantial gainful employment activity productive in nature, provided that the Plan Administrator finds, and a physician or physicians designated by the Plan Administrator certify, that the Disability is likely to be permanent during the remainder of the Participant’s life.”

What is a partial disability?

“You are considered partially disabled if, due to sickness or accidental bodily injury, you are unable to perform the material and substantial duties of your occupation on a full-time basis, but can work at your own occupation on a part-time basis or at another occupation on either a full- or part-time basis.”

“The result of an illness or injury which prevents an insured from performing one or more of the functions of their occupation.”

“A condition in which, as a result of injury or sickness, the insured cannot perform all of the duties of his occupation but can perform some. Exact definitions vary from policy to policy.”

“A disability that prevents an insured from engaging in some of the duties of his or her usual occupation or from engaging in the occupation on a full-time basis.”

What is “residual disability”?

Residual disability provisions, if provided in the policy, cover those who have begun to recover from total disability but continue to have limitations. Residual disability may be defined as an inability to earn your former salary (usually below 80%) or an inability to work full time or perform the same duties you performed prior to illness.

What is an elimination period?

The elimination period is a waiting period to determine that you are truly disabled. It usually ranges from three to six months.

Do you have questions about Long Term Disability? Contact the Detroit ERISA lawyers at Allan W. Ben, PC. The attorneys at Allan W. Ben P.C. represent long-term disability and short-term disability insurance claimants throughout the United States. We welcome the opportunity to speak to you with a free phone consultation regarding your disability claim.

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