If you’ve filed a long-term disability (LTD) claim and your insurer says you are “not totally disabled,” as per your policy, you may be wondering what that really means, and why it is being used to deny your benefits. So, what does “not totally disabled” mean under disability insurance? Unfortunately, this term is often used ambiguously and unfairly by insurance companies to delay or deny rightful claims. Can you challenge it? In this blog, we’ll explain how insurers define “total disability,” how they use this definition against claimants, and what you can do if your LTD benefits have been denied on this basis.
What are disability benefits?
If you work for an employer, chances are you are part of a group benefits policy that includes short and long-term disability insurance. The disability benefits are there to provide monthly income if you become unable to work due to injury or illness. Short-term disability benefits cover you for a shorter period (as the name suggests) and if you’re illness requires you to be off longer, long-term disability comes into play.
What does “Total Disability” mean under insurance benefits?
Your LTD policy is a contract between you and the insurance company. There are different definitions and clauses at play within the policy that define the “rules” around the contract. One of the important rules revolves around the definition of Total Disability. This is the language the insurance company relies on in determining whether a person is disabled under the LTD policy, or not.
A sample definition might look like this:
An employee will be considered Totally Disabled:
- While the employee is continuously unable due to an illness to do the essential duties of the employee’s own occupation, during the elimination period and the following 24 months, and
- Afterwards while the employee is continuously unable due to an illness to do any occupation for which the employee is or may become reasonably qualified for by education, training or experience.
There are a few moving parts to this definition, so let’s break it down. Totally Disabled is often governed by two periods. For the first two years, the insurance company will evaluate your condition and determine whether the injury or illness stops you from performing the essential duties of your own occupation. This is the job you were doing right before you left work.
After the two-year mark, the definition changes and it becomes more difficult for the employee (i.e.: you). The test becomes broader and considers whether the injury or illness prevents you from performing the duties of any occupation for which you may be qualified (or become qualified) by education, training or experience.
Different policies will have different language but will essentially allude to a similar definition as provided above. It’s important to check your policy so you are aware of the definition and test that applies to your circumstance.
What does not “Totally Disabled” mean under disability insurance?
The insurance company has denied me, indicating I am not “Totally Disabled” according to the policy wording. LTD insurers will often cherry pick certain medical evidence or information to support a denial of benefits. Sometimes, they will hire internal medical consultants to conduct a “paper review” of your medical records and rely on the findings of this consultant in denying your claim. Sometimes they will look at your social media and determine you are not Totally Disabled, based on their definition of Totally Disabled. It’s a very subjective determination.
What are my options?
Remember, you have rights! You can challenge improper denials with the help of a disability lawyer, like one at Whitten & Lublin. You’ve paid premiums for disability insurance and it’s important to exercise your rights if you’ve been wrongfully denied your LTD claim.
Don’t let yourself be bullied by the insurer. Take control with us in your corner.
If your Insurer is saying you are not “Totally Disabled” as per the policy wording and you have filed an appeal and the insurer has maintained their original denial, it’s time to speak to a disability lawyer at Whitten & Lublin. We offer free consultations for short and long-term disability claims. Contact us online or call 416 640 2667.
Author – Aman Chaggar
