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Many people on long-term disability worry about whether they will continue to receive benefits beyond the two-year mark, and for a good reason: most long-term disability insurance policies have a definition of disability that changes after two years, or they limit claims for certain conditions to two years.
Changes in the Definition of Disability
The primary reason long-term disability benefits are cut off after two years is that under most disability policies, there is a change in how they define the term disability. Under most policies, for the first two years, you meet the definition of disability if you cannot perform the material duties of your occupation. This is often called the own occupation or “own occ” period because the insurance company determines whether you can perform your occupation.
For instance, if you were working as an auto mechanic, that is considered your occupation. If you injure your back, you may not be able to work as a mechanic anymore because you cannot perform the job’s essential duties, such as bending, reaching, pulling, pushing, and using your back muscles in the way necessary to work on cars. However, in many policies, the definition of disability changes from “own occupation” to “any occupation” after two years or 24 months.
The insurance company will look to see if you can perform the material duties of any occupation, often referred to as any occupation or “any occ” period. During a claim review under the “any occupation” standard, typically after two years of receiving long-term disability benefits, the insurance company will look to see if you can work any occupation. This could be working as a salesman or secretary in the auto body shop instead of a mechanic or working in another field altogether.
Therefore, in many cases, the insurance company will say:
“We agree that given your medical problems, you cannot perform the material duties of your job, but after two years, we think that there are other types of work that you may be able to perform, even taking into account your medical condition.”
This is why they often send letters cutting off long-term disability benefits after two years.
How Insurance Companies Evaluate Transferable Skills
Insurance companies assess transferable skills through vocational experts to gain clarity on an individual’s abilities and their impact on claim decisions. These experts evaluate a person’s skills, experience, and education to determine if they can perform other types of work. They consider factors such as physical limitations, mental capabilities, and job market conditions to provide a comprehensive assessment. This process plays a crucial role in determining eligibility for benefits.
The SSA Says I Am Disabled, So Why Was My LTD Claim Cut Off?
LTD insurance companies and the Social Security Administration have different definitions of disability, which can significantly affect claimants.
While the SSA requires claimants to prove that they are unable to engage in substantial gainful activity due to a medical condition expected to last at least one year or result in death, LTD insurance companies often define disability as the inability to perform the duties of one’s own occupation or any occupation for which the claimant is reasonably suited by education, training, or experience.
This disparity means that individuals who qualify for benefits under the SSA’s definition may not necessarily qualify for benefits under their LTD policy, creating additional challenges and financial strain for claimants who must navigate these differing standards.
Benefit Limitations for Specific Conditions
The most common benefit limitations for specific conditions are those related to mental health claims. We also see limitations creep into the physical impairment category.
Mental/Nervous Conditions
Most group policies also limit how long a claimant can receive benefits for mental, nervous, and psychological impairments. If you are receiving LTD payments due to depression, anxiety, post-traumatic stress disorder, agoraphobia, obsessive-compulsive disorder (OCD), or a similar impairment, you may be limited to receiving 24 months of benefits. However, if you are institutionalized or confined to an inpatient treatment facility when your 24 months expire, most insurance companies will continue to pay benefits until you are no longer hospitalized, subject to a cap.
Note: The rationale behind this two-year limitation on disability coverage from the insurance company’s point of view is that many of these mental/nervous impairments can be exaggerated or outright faked. There is a possibility that the claimant is pretending to be unable to perform any occupation. While this policy does keep insurance policy premiums lower, it provides little comfort to those long-term disability recipients with bona fide mental illnesses whose benefits are terminated after only two years.
There are often exceptions to this time limitation for organic mental disorders like dementia and organic brain disease, and perhaps even mental illnesses such as schizophrenia and bipolar disorder. The specific language in your policy determines which conditions are subject to the two-year limitation and which are exempt from this limitation. Policies offered by different insurance companies will use different language to describe the terms of the disability policy.
If you also suffer from a physical condition, your insurer may try to say that your mental health issues are the sole cause of your disability. A disability attorney can help determine if a mental health limitation applies to your claim. If the insurer has inappropriately applied a mental health limitation to your claim, your attorney can help you appeal the decision.
Subjective Complaints and Non-Verifiable Impairments
Some policies also have a two-year limit on long-term disability benefits for chronic pain conditions such as arthritis and chronic back pain and for medical conditions that are primarily diagnosed based on “subjective,” “self-reported,” or “non-verifiable” complaints, including chronic fatigue syndrome and fibromyalgia. However, some insurance policies may carve out exceptions to this limitation.
Neuromuscular, Musculoskeletal, and/or Soft Tissue Conditions
Your policy may also state that benefits are limited to 24 months for neuromuscular, musculoskeletal, and/or soft tissue conditions. Understanding your policy’s terms and conditions is crucial.
For example, I have seen a MetLife policy with a 24-month limit on neuromusculoskeletal and soft tissue disorders, except where there is certain objective evidence. Working with medical professionals who understand these details can strengthen your claim.
Conditions Related to Alcohol and Drug Abuse
Disabilities caused or contributed to by alcohol or drug abuse will almost always be subject to the same 24-month limitation.
Appealing A Wrongful Termination of Your Long-Term Disability Claim
If your long-term disability benefits get cut off after two years, filing an appeal within the specified time frame mentioned in the cutoff letter is crucial. Your cutoff letter should outline the deadline for filing any appeals, usually around 180 days from the date of the letter. Many people make the common mistake of not meeting this deadline when fighting for long-term disability benefits. Given the complexities of long-term disability claims, having the right legal support can be the key to securing the benefits you rightfully deserve.
Ortiz Law Firm Can Help Appeal Your Long-Term Disability Denial
Long-term disability attorney Nick Ortiz has been advocating for the disabled since 2005 and understands the sneaky tactics used by insurance companies to deny claims. We handle claims with disability insurance companies such as New York Life, Lincoln Financial, Reliance Standard, Prudential, and The Hartford. We can assist you in gathering your documents and statements from your doctors, reviewing your claim, and even hiring vocational experts to speak on your behalf. If you want to discuss your long-term disability claim with an attorney, please call us at (888) 321-8131.
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