What is Essential Duty Under Your Long Term Disability Policy?

 

Make sure the insurance company is using the right definition of disability.

You'd be surprised, but this comes up a lot. When you bought your insurance long term disability policy, or when your company did and provided coverage to you as an employee, they were basically paying for a specific definition of disability. The term “disability,” or “disabled,”  is specifically, and carefully, defined in your insurance policy (by the insurance company). So how it is defined is critically important - and governs just about every aspect of your claim.

Sometimes the insurance company will terminate or deny benefits after reviewing the claim using a different definition of disability

There is a typical clause, sometimes called the "essential duty" cause that defines "Disability" like this: You are prevented from performing one or more of the Essential Duties of: 1) Your Occupation during the Elimination Period…”

 

In an ERISA long term disability claim, that work, that means you are disabled (and should get benefits) if you can prove you can't perform one of your "essential duties" due to injury or illness, sometimes this is also tied to the amount of time you can work, so an “essential duty” may include the ability to work full time, or 40 hours per week. 

 

If you received a denial letter from the insurance company, you have to review it carefully (or have us review it for you). One of the first things to look for is the proper definition of disability. So, in this example, if the disability insurance company denial letter indicated your long term disability benefits were being denied because you need to prove "you must be unable to perform the duties of your occupation” you might not even notice the different definition they used to deny benefits.

 

Here's is why using the wrong, even slightly different definition changed the case. Under that definition, you have to be unable to do each and every job duty to get benefits. Under the terms of your insurance policy, however, you would be entitled to benefits if your injury or illness prevented you from doing just one job duty.  As you can see, using the wrong definition allows the insurance company to say you aren't disabled.

 

Too many people with legitimate injuries and illnesses fall for this trick.  You absolutely have to read your insurance policy or contract and make sure the denial letter terminating your benefits cites the correct terms, conditions and definitions in your policy. Above all else, don’t take the insurance company's word for it.

 

Whether the insurance company makes an honest mistake, doesn't know, or is deliberately trying to screw you, it doesn't matter - the result (a denial of benefits you deserve when you can't work) is the same.

 

So if you’ve received a denial letter, call us at (202) 393 - 3320 and let us help.