When applying for long-term disability, you might come across the phrase gainful employment. Suppose your disease or injury stops you from holding any job where you would make at least sixty percent of your pre-disability income. In that case, your LTD insurance provider should pay you gainful employment benefits. Most insurers use complicated methods when determining whether your disability prevents you from working in any occupation or own occupation. Therefore, you require a qualified lawyer to increase your chances of receiving the benefits you deserve.
Unpacking the Meaning of Gainful Occupation
A gainful occupation is a job where you earn more than 60 percent of your pre-disability income. It implies that before the insurer can terminate your benefits or deny the disability claim under any occupation LTD plan, the firm should prove that you can do a job that will pay you sixty percent of your previous income, considering your experience, education, and training.
Long-term disability policies differentiate between "any occupation" and "own occupation" disability. Any occupation requires the incapability to do any job for you to qualify, while "own occupation" means the inability to do certain duties of your current job. A gainful occupation aligns with the definition of any occupation.
Please note that sixty percent is common, but not across the board. Therefore, confirm the specifics of your insurance policy. Some policies compensate individuals who have a greater loss of income more; in this ccase, gainful occupation will offer the individual a greater percentage of their pre-disability income.
Defining Reasonably Suited
Before your insurance provider denies you any occupation LTD policy, it cannot just presume that you could perform any job. Instead, you should be reasonably suited to do a gainful occupation founded on your place of residence, education, medical limitations, and skills.
Factors that might make a particular occupation irrational for a person to perform include the following:
- There are no job positions within their occupation within a rational commute from their home
- Their physician has not released them from engaging in the required job tasks.
- The job criteria are above their education level or skills. (While they cannot reasonably do a job they are underqualified for, insurers rarely consider that you could be overqualified for that job.)
- The job will prevent you from making medical appointments.
How Insurance Providers Assess Gainful Occupation
When applying for gainful occupation benefits, your insurer will investigate your claim. The assessment will focus on your work background, functional abilities, and medical conditions.
Your Insurer will Review Your Medical Records
Your insurance provider will not approve your claim based on a description of signs and symptoms. Instead, it will analyze your medical reports to look for proof of disability. You can submit copies of your fact-based proof, like diagnostic testing results. The company will review the medical records upon receipt.
The insurer cannot obtain your medical permission without your consent. You must sign your medical release, which you can cancel or withdraw at any time.
During your claim process, your insurer can require you to undergo a functional capacity evaluation or independent medical examination. The insurer will cover the cost of the examinations. An independent medical examination focuses on disability, whereas a functional capacity evaluation assesses your ability to perform work-related tasks. The FCE is more objective.
After your insurer schedules an FCE or IME, you should attend the examination. Otherwise, the company will deny your benefits. Be truthful during your examination. Avoid exaggerating your signs and symptoms: your examiner will mention your exaggeration in their report, and it could result in benefits denial. Likewise, avoid minimizing the symptoms; the physician might believe you can perform work-related tasks, and it could lead to your claim denial.
Your Insurer will Conduct a Vocational Analysis
After the insurer has your medical details, they can choose whether work limitations are relevant to your claim. Work restrictions involve mental and physical abilities. After setting work restrictions, the firm will conduct a vocational analysis to determine whether the limitations will permit you to work.
A summary plan description will include your insurance plan's definition of disability. Depending on the plan, your insurer will compare your limitations to your previous job or other jobs. The company will deny your claim if it believes you are capable of working.
After the vocational assessment and medical review, the insurance firm will issue its decision, either denying or approving benefits. The firm can take months before issuing its decision. If it denies your LTD disability claim, it should explain the reason for the denial. Your denial letter should elaborate on the appeal process.
Other Relevant Documentation to Demonstrate Your Incapability to Work in a Gainful Occupation
Ensure you provide your insurance provider with relevant medical proof, including your physician's opinion on your limitations. That way, the insurance can review what kinds of jobs you can complete. The type of proof you will require depends on the disabling condition. Diagnostic imaging like X-rays, prescribed medications, and treatment plans support physical health conditions best, while mental diseases might require your psychologist's or therapist's counseling notes. Your doctors' reports should discuss the nature of your disease or disability, its seriousness, and its effects on your ability to complete work-related duties.
You can also submit proof of your employment history. It may include records of your job description, any accommodations your previous employer made, and your past employment history. The details help establish a baseline of your work abilities before the onset of your disease or disability.
You can also use a functional capacity evaluation, which objectively assesses your mental and physical abilities in relation to work duties. Occupational therapists conduct this evaluation and comprehensively analyze what you can and cannot do in a work setting.
Affidavits or statements from your former colleagues and employers can offer more insights into your observed limitations and work performance. The personal account can corroborate employment and medical records, providing a detailed view of your work-related challenges.
Financial records, like pay stubs and tax returns, can offer evidence of your previous income and current financial status. The details can prove the economic impact of being unable to work and verify your LTD claim for benefits.
Proof of interviews, job applications, and participation in vocational rehabilitation training can demonstrate your willingness to work and your efforts to overcome your limitations. They also prove that your incapacity to work gainfully is not because of the absence of effort.
Who Determines Whether You Can Perform Another Job
Insurance providers hire vocational experts to prove there are more jobs that you can do and to decide the compensation related to those jobs. Vocational experts are familiar with the specific details of the labor market and have experience in placing individuals with disabilities in suitable employment opportunities.
As with any professionals, vocational experts can agree or disagree with each other. Vocational experts hired by the insurer will most likely conclude that you will acquire gainful employment, while a VE hired by your attorney will have a different opinion.
While the vocational experts' opinion plays a significant role in determining whether you will receive benefits, the plan administrator (claim administrator) decides whether the insurer will approve or deny your claim.
What to Do After Your Insurer Denies Your Claim Because It Argues That You Can Perform Another Job
If your insurance provider's vocational expert claims that you are reasonably suited to perform another job and denies the claim, you can file an appeal. Your experienced lawyer will cross-examine the insurer's VE through oral depositions or written questions. Your attorney can also work with a vocational expert who can elicit a testimony that is beneficial to your claim, assisting you in acquiring benefits after appealing the case.
Depending on the long-term disability policy, you might file for Social Security disability benefits if you prevail in the appeal. If the Social Security application is approved, you should pay back the insurer the LTD benefits.
If you do not prevail in the appeal and cannot work a full-time job for more than a year, you could be eligible for Social Security disability benefits, irrespective of whether the insurer paid the LTD claim.
Some insurance firms will require you to reimburse the whole overpayment immediately you receive your Social Security, while others will allow you to lower your payments monthly until you satisfy your overpayment.
If you fail to pay your insurer from the Social Security backpay, it will stop your LTD benefits until your overpayment is repaid.
Appealing Your LTD Insurance Claim Denial
The process of appealing your LTD insurance denial involves first collecting missing details. If your denial was because of technical issues, like missing forms, fill in the forms and include them in your appeal. Ensure your insurance firm has all the necessary parts of your medical records.
Sometimes, plan administrators and insurance companies fail to gather all relevant medical documents about your LTD benefits claim. Therefore, find the documents that the insurance firm used to determine your case. If something is missing, notify your claims representatives.
Request any information regarding when your insurer received and requested your medical records, and collect all missing documents to include in the appeal.
Secondly, you should promptly employ a lawyer who will represent your case. Do not wait until you receive your denial notification to enlist a legal representative.
Your legal counsel will enhance the chances of obtaining the best possible case outcome at your appeal by securing additional medical proof or enlisting the help of other professionals, including doctors. Most plan administrators and insurance firms take an LTD matter seriously when you have a legal representative.
Ways You Can Compile Favorable Proof
You should gather your administrative records with convincing evidence before concluding your LTD insurer's internal appeal process. Under ERISA law, federal courts do not consider any evidence that you had not previously presented to the plan administrator or insurance firm during the internal appeal process.
Note that the disability documentation may be tailored to make you respond in a manner that justifies your claim denial. Therefore, you should answer all questions truthfully and, if necessary, request additional sheets to add more favorable proof to your file.
Establish If Additional Tests Can Support Your LTD Case
When making denials, insurance firms usually imply that the absence of objective proof is the reason for denying an LTD claim. Consult your claim representative to know if additional objective testing can support your claim. You may strengthen your claim by undergoing the following tests:
- MRIs
- X-rays
- CT scans
- Blood tests
Presenting more objective medical proof increases the chances of your insurer overturning a claim they have previously denied.
Request Expert Testimony or Letters
Some forms of non-medical proof could bolster your LTD claim benefits, including the following:
- Written observations by loved ones and friends regarding your limitations
- Vocational expert testimony
Request a Written Opinion from Your Doctor j
You should ask your doctors and experts for written opinions on your work-related restrictions due to your medical health condition. Your lawyer will then ask the doctor specific questions based on the circumstances surrounding your claim.
Professional opinions are vital as you attempt to persuade the insurance firm of the disability benefits. Most physicians charge a fee for filling out the LTD paperwork, which is more than worth it. If your doctor is unwilling to assist with the written opinion, and you think your condition is severe, consider changing physicians.
Find a Seasoned LTD Attorney Near Me
Suffering a severe injury or debilitating disease can change your life for good. For instance, being unable to work can lead to financial challenges that are difficult to overcome. Gainful employment can help you. Unfortunately, profit-driven insurance firms can hinder the process and deny claims for unclear reasons. The application process can sometimes be confusing and complicated. You should not embark on the journey of pursuing the benefits you deserve without the assistance of a California-based skilled lawyer.
At Lelad Law, we understand the immense pressure you face when you can no longer work, and that is why our compassionate lawyers can guide and advocate for you through the LTD process, including filing your claim, addressing claim denials, and appealing the insurer's decisions to safeguard your benefits. Once you call us, we can listen to you and develop a strategy tailored to your specific needs and circumstances. Please contact us at 866-449-6476 to schedule your initial consultation and discuss your case.
