Texas long term disability attorney Marc Whitehead, Board Certified Disability Attorney, explains the legal definition of disability.
Long Term Disability Insurance Companies are notorious for denying legitimate claims based obscure disability definitions contained in the policy. There is no one, legal definition of disability. Every Insurance company has a different definition of disability as does the Social Security Administration and the Veterans Administration.
The term Disability is defined by the insurance contract, usually it’s something along the lines of-
“Due to sickness or injury the employee is unable to preform the material and substantial duties of his or her own occupation”
However, most policies shift the definition to a more difficult “Any Occupation” standard after a period of time, usually 24 months. The insurance company gets to define disability, interpret the definition, and decides whether or not a claimant is disabled. The insurance company also decides whether or not the claimant will receive benefits. This creates an obvious conflict of interest.
Because the insurance company decides whether or not a claimant is disabled, they will use their own employees, either a nurse or an in-house doctor to review claimants medical records. Many times this in house consultants will have a different opinion then the claimants own treating doctor. The insurance company will state that the claimants doctors opinion is not supported by the medical records.
The Supreme Court has looked at this issue and decided that the treating physician rule, as used by the Social Security Administration, does not apply to disability insurance determinations. The treating physician rule says if a treating doctor says that a claimant is disabled that opinion is entitled to great weight. In private disability plans the US supreme court has held that a claimants doctors opinion that the claimant is disabled should be held as a factor in the determination of disability but it is not binding on the insurance companies determination.
So what if they Social Security Administration says that you are disabled, isn’t that enough? For a person under the age of 50 a Social Security Administration Definition of disability is actually a tougher standard then a long term disability insurance definition. Because a claimant must be unable to work at any occupation in the national economy. But because Social Security Rules differ slightly from the disability insurance companies, the insurance company will ignore an award of benefits by the Social Security Administration by stating that the rules are simply different.
But what if a Long Term Disability Insurance Company helped you get your Social Security Disability in the first place? The insurance company is more then happy to help a disability claimant get social security disability benefits because it helps them financially. The insurance company contracts with another company that represents claimants against the Social Security Administration. The insurance company will reduce a claimants monthly LTD benefit by the amount the claimants receive from the Social Security Administration and will even demand that the claimant pay back the insurance company back benefits received from Social Security.
