What does the definition of "own occupation" mean under your ERISA disability policy?
ERISA long-term disability insurance policies usually pay benefits if you can't work in your own occupation - you can't perform the material duties of your job. So when they deny your claim, insurance companies will often try to use a general job description of your work so that it will be easier to deny benefits - there are Department of Labor classifications or definitions of jobs, for example, and you may generally fit that category - but it doesn't describe all the work activities you do every day.
Here's a common example from a federal court case - remember, ERISA disability appeal denials go to federal court if you want to sue the disability insurance company for your benefits.
In this case, the worker was a wine salesman for a distributor, and as part of his job he had to deliver cases of wine weighing more than 20 pounds to stores, so he could create displays to showcase the wine and stock the shelves. Plus, he drove nearly 2,000 miles every month traveling to different stores. Then he had a back injury.
Like most disability insurance companies, Liberty Life Insurance Company tried to "redefine" his occupation. Instead of using the activities he actually did on the job, they used a generic job description for a "sales representative" so evaluated his job as a light one with very little physical demand.
The court in that case did not agree. Instead, the court ruled:
That the insurance company must review the material duties of the worker's actual job and make an assessment of how those duties align with the position as it is normally performed in the national economy.
That the insurance company and its vocational evaluator disregarded the physical demands of the worker's actual job.
That since the insurance company had a job description with the actual physical requirements listed in the job description, they couldn't just use a generic job description.
The insurance company's own internal files said the job was a heavy duty occupation.
That since the vocational evaluator was an employee of the insurance company, there was a conflict of interest.
Remember, when you analyze and draft your appeal to the insurance company after benefits are denied, you must make all of your legal and factual arguments and put in all of your evidence - there is no second chance or ability to do this after the appeal is denied, even if you file a lawsuit. A long-term disability attorney can put you in the best position to formulate and include all of the evidence you need.
If you received a denial letter from your insurance company, call us at (202) 393 - 3320. We’re happy to help.