There’s a misconception among holders of long-term disability (LTD) insurance policies that the company issuing the coverage will simply “pay up” when workers say they are disabled and can no longer perform their job duties. However, as with most things in life, it’s just not that simple.

Disability insurance attorneys Greg Dell and Stephen Jessup shed some light on what really happens, specifically the importance of clarifying the claimant’s pre-disability occupation and the specific duties involved. There’s high potential for a disability claim denial and eventual ERISA lawsuit if the disabled policyholder doesn’t know exactly how to present the crucial issue of defining the occupation – and proving how his or her disability now makes it impossible to perform that particular job.

Defining the Occupation

Once a worker becomes disabled and decides to claim benefits provided by his disability insurance policy, everything starts with the initial application. Disability lawyer Greg Dell notes that his Dell & Schaefer law firm handles thousands of long-term disability applications for claimants across the country, and he stresses that the intricacies of defining the occupation can be the make-or-break component of whether the claim is approved or denied.

Fellow disability lawyer Stephen Jessup agrees and explains that every insurance company has its own set of forms, which contain similar questions but are catered to the language in each company’s particular disability policy. They’re trying to get at different types of information, and it often relates to the classification of job duties in the Dictionary of Occupational Titles (DOT) or other vocational resources. The Department of Labor also has stated standards for each occupation, designating them by terms such as “sedentary,” “light duty,” and “medium, heavy, or very-heavy duty.”

One problem with these predefined terms is that insurance companies use them to determine how your job is performed in an ideal situation in the national economy. This overlooks how a worker actually performs a particular job for a specific employer at a specific location. According to Stephen Jessup, a disability insurance company can manipulate the generic DOT label by looking up a job title and its associated classification (such as “sedentary,”) and then getting a disabled person’s attending physician to answer a targeted question about whether his patient can perform related duties.

For example, the insurance company may look at the “sedentary” definition from DOT and see that it requires the person be able to sit for a certain number of hours per day, lift a stated number of pounds, and take a minimum number of breaks during the day. Then, they’ll contact the claimant’s doctor.

“They’ll send that DOT description to a doctor … sometimes, they don’t even tell them what the person does,” says Greg Dell. “They just say, it’s a sedentary job, do they have any restrictions, limitations stopping them from doing a sedentary job?” 

If the doctor gives a quick reply saying there are no restrictions with sitting, bending, lifting or similar activities, the insurance carrier says, “Okay, you’re not disabled, because you can do a sedentary job.”

When a competent and skilled disability insurance lawyer represents a disabled policyholder, that game changes. Whether it’s in the initial application for benefits, an appeal after a disability denial, or an eventual lawsuit when the appeal is rejected, attorneys at Dell & Schaefer get very detailed about presenting the occupation. They go way beyond the typical one or two lines provided in the application for describing the occupation and job duties.

“We really list out what it entails. It can come from the employer’s job description … but we do attachments and addendums, where we really work with the client to list what a typical day (or week) may look like,” states Dell.

LTD Claimant Examples

A common type of claimant needing assistance from a disability lawyer is a person working in the IT field, perhaps a computer engineer, computer consultant or similar. The first thing a disability insurance company is going to assume, according to Stephen Jessup, is that the employee works at a desk and that he performs his work at a sedentary level in the national economy.

The insurer will likely claim that he can do sedentary work regardless of what the job actually entails – and will, consequently, deny the claim. But Jessup points out that IT doesn’t work in a bubble and that the potential physicality of the job may be overlooked, such as moving computer equipment and monitors, working out in the field or driving to assist clients.

It’s also assuming that the reason the employee cannot work is purely physical. There are often cognitive aspects, even with physical claims. For example, if the IT consultant becomes disabled because of a back or neck issue, there will be a lot of pain, which almost inevitably involves medication. Are your faculties for doing your job still there?

Greg Dell turns the tables and gives a hypothetical scenario of a claim reviewer, such as one from an insurance company, who perhaps has an ongoing neck issue. In the course of a day, that reviewer may need to get 10 things done because she’s evaluating or reviewing up to 100 different claim files. She gets 30 unexpected phone calls that day; she writes up responses to four appeals; she reviews hundreds and hundreds of pages of medical records. That neck, which is affected when she sits in a certain position for more than five minutes, is going to start hurting. And it never stops.

“And what do you do when you’re not feeling well? You’re not focused,” Greg Dell points out. “I mean, think about common sense, when someone doesn’t feel well just in a social atmosphere, they’re not all there.” 

People living with debilitating chronic pain, adds Stephen Jessup, spend more time thinking about how they’re feeling like garbage than performing the duties of their job. “And that’s what’s really happening.”

Moving Forward With the Claim

The way to get around all this, according to Greg Dell, is to not even necessarily focus on the job title. So, when he and fellow disability attorneys present a claim for a certain occupation, they move away from the job title and focus instead on the duties. What’s known as a “substantial maturities” of your occupation comes into play as well, but it’s the “duties” part that’s really important, notes Dell.  

Every single person’s duties are intrinsically unique. That’s why it’s essential to anticipate the classification that the insurance company will attempt to put you into, and then get a very detailed description and explanation into the record. It takes a lot of time and experience to “beat them to the punch” and to then fight a denial based on the insurance company ignoring the occupation portion of the documentation.

 “So, we’re really laying a very strong foundation for the person moving forward, which is super, super important,” stresses Greg Dell. “It also prepares you for restrictions and limitations if you have a ‘change of definition’ that’s going to go from ‘your occupation’ to ‘any occupation,’ which can happen at the two-year mark.”

This means that the disabled person, even if she’s been receiving disability benefits for quite some time, can suddenly have to prove that she is incapable of performing any occupation at all ­– not just her pre-disability job position.

The multiple layers of seeking and obtaining well-deserved disability insurance benefits can be intimidating on so many levels. That’s why attorneys at disability law firm Dell & Schaefer are there to help. Whether you’re at the beginning of a long term disability application or have already filed, you can call or use the contact form on the company website. The initial consultation is always free, and they work with policyholders anywhere in the country.