Disability is defined in your disability insurance policy. This definition can vary from policy to policy. Three commonly used definitions include own-occupation, modified own- occupation and gainful occupation. It is also important to understand that policies may change the definition of "disability" after you have received benefits for two (2) years or some other time frame.
Own-occupation is the most flexible definition of total disability for the insured. If the insured is unable to perform the material and substantial duties of his or her occupation at the time you become disabled, the disability insurance company will pay the claim even if you are working in some other capacity or employment that is not similar to your occupation.
Modified own-occupation is also referred to as income replacement insurance and is the most widely used definition of total disability in policies today. Under this definition, a disability insurance company will pay your claim if you are unable to perform the material and substantial duties of your occupation and you are not working in any other occupation.
Gainful occupation is the most restrictive definition and the most commonly used by employer group long term disability policies. Under this definition, a disability insurance company will pay your claim if you are unable to perform the material and substantial duties of your occupation, or any occupation for which you are deemed reasonably qualified by education, training or experience.
The Law Firm of J.P. Gonzalez-Sirgo, P.A. represents individuals that have had their valid long term disability benefits denied, delayed or terminated irrespective of whether the policy was purchased individually or issued through an employer group policy. The firm is available to assist individuals with the initial application process, during the administrative appeals process, handling denials of claims or termination of benefits, litigation in state or federal court, and negotiating a one-time lump sum settlement or buy-out. Please contact our office to discuss your case in more detail.