What is “Gainful Occupation”?

Question: My insurance company says that I can work under “gainful occupation.” What does that mean?

Most long term disability policies are divided into two disability types: “Own occupation” which is defined as being unable to perform the duties of your own occupation and “any occupation” is defined as not being able to work in any gainful occupation based on your salary, training, experience, and education. “Any occupation” is very subjective and usually is applied after the first 24 months that you have been disabled and receiving benefits for own occupation.

In this article, we will outline the meaning of gainful occupation and who decides if you have a gainful occupation.

  • What is a Gainful Occupation?
  • Who Decides Whether I Can Work Any Occupation?

What is a Gainful Occupation?

Essentially, a “gainful occupation” is an occupation that provides you with at least 60% of the salary you received before your disability. The insurance company must prove that you can perform “any occupation” based on your previous experience, education, and can provide you with at least 60% of your salary. If the insurance company can prove this, they will have a reason to deny your claim.

Although 60% of a person’s salary is standard, it is not always the case. Reading your policy is the only way to know for sure. Policies can range from 20%-80% depending on the insurance company.

Here is an example: A surgeon is involved in a severe car accident that was no fault of her own. Her hands sustained nerve damage causing her to need long term disability benefits while she recovers. After two years, she still cannot safely go back to work as a surgeon. If her salary was $360,000 a year, then the insurance company must prove that she can still earn at least $216,000 in another “gainful occupation,” otherwise her claim will be approved.

What it Means to be “Reasonably Suited”

The term “reasonably suited” refers to an occupation that you can work that is based on your previous work experience, the location, your education, and the limitations of your disability. For the job to be “reasonably suited,” it must meet several criteria:

  • The location of work must be a reasonable amount away from your home.
  • The job must be in line with your current skill set.
  • The job must allow you to miss work for medical appointments related to your disability.

While “reasonably suited” can be subjective, these are useful guidelines to help you when building your claim.

Who Decides Whether I Can Work “Any Occupation”?

Insurance companies will use vocational experts to help prove that you still have employment options out there. A vocational expert is a person who has expertise in the labor market and often has experience placing disabled people in new positions of employment. They rely heavily on data resources like labor statistics and employer surveys (which are very subjective). A vocational experts testimony is valuable, and the decision to approve or deny a claim will be in the hands of the claims administrator at the insurance company.

Oftentimes, vocational experts will disagree. An experienced disability attorney will help you build a strong case and will hire its own vocational experts to give their opinion and data as well. If your claim is denied, it is good to have this evidence in your administrative file for an appeal.

In conclusion

While proving that you are disabled under “own occupation” is slightly easier, most disability policies switch over to “any occupation” after two years. “Any occupation” is much harder to prove since the insurance company will use their own vocational experts and has the final say of approval for your claim. If they cannot find you an occupation that meets the standard for “gainful occupation,” you are entitled to receive your benefits.

An experienced disability attorney can help you navigate your way to a successful claim. Disability attorneys do not get compensated unless you do. If you would like to have a free consultation, contact the Nick Ortiz Law Firm. The call is entirely free, and you are under no obligation to use our firm. We are happy to answer any questions you may have. Give us a call at (888) 321-8131.

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