Change is inevitable. But what does change mean when it comes to your long-term disability policy. If you’ve been receiving long-term disability (LTD) benefits, you may assume your financial support will continue as long as your condition keeps you from working. But many people are caught off guard when their insurer reassesses their claim at the two-year mark, a critical milestone known as the Change of Definition. At this point, the criteria for receiving benefits shifts, and the insurance company may argue that you are now capable of performing “any occupation,” even if you still can’t return to your own occupation.
Understanding what the Change of Definition means, why it’s such a pivotal time in your claim, and how to protect your rights if your benefits are at risk is critical. Whether you’re approaching this two-year threshold or have already received a warning or denial, knowing what to expect can make all the difference.
What is disability coverage?
A disability policy is a contract between your employer and the insurance company. You or your employer pay premiums to the insurer in exchange for insurance coverage. If you’re part of a group benefits policy, you might be insured for vision, dental and extended health benefits. Short- and long-term disability is available through the group insurance policy.
How to apply for long term disability insurance benefits?
If you have suffered an accident, illness or injury that has taken you off work, consider applying for short or long-term disability benefits. At the outset, you can make a claim for short term disability by completing the disability claim application package which has three forms:
- Plan Member Statement – completed by you
- Plan Sponsor Statement – completed by your employer
- Attending Physician Statement – completed by your doctor
You’ll be responsible for completing the Plan Member Statement and having your doctor complete the Attending Physician Statement. The employer should complete the Plan Sponsor Statement and forward it to the insurance company.
Once your application is complete and all forms submitted, the insurance company will notify you if they have approved, denied or pended your claim.
If your condition has kept you off work for longer than anticipated, your benefits will either transition to long-term disability or you’ll need to complete a long term disability application submitting the same forms to the LTD insurer.
Long term disability policy terms – what is the difference between own occupation vs. any occupation?
When on LTD, your case manager will likely remind you of the Change of Definition LTD period. Let’s break down what that means.
Your LTD policy will define what it means to be Totally Disabled.
Sample policy language
Consider the following sample definition:
The insurer will apply the following criteria in determining an Employee’s entitlement to disability benefits:
- The Employee has been continuously Totally Disabled through the Qualifying Period.
- The insurer receives medical evidence documenting how the Employee’s illness or injury causes restrictions or lack of ability, such that the Employee is prevented from performing the essential duties of:
- His own occupation, during the Qualifying Period and the 2 years immediately following the Qualifying Period; and
- Any occupation for which the Employee is qualified, or may reasonably become qualified, by training, education or experience, after the 2 years specified in part i. of this provision;
- The Employee is receiving from a Physician, regular, ongoing care and treatment appropriate for the disabling condition, as determined by the insurer.
Why the Change Matters
Even though the language may look similar, the definition outlines two different definitions. When an insurance company initially evaluates your LTD claim, the insurer determines whether your illness or injury prevents you from completing the essential duties of your own occupation. During the own occupation stage, the test is easier for the claimant (ie: you) as the definition restricts the insurer from considering other types of work that you might be suited for.
After the two-year own occupation period is up, the definition changes and becomes more difficult for the claimant. The insurer no longer considers whether your condition stops you from doing the essential duties of your own occupation, but rather, evaluates your claim on whether you can do the essential tasks of any occupation [that you are qualified or may reasonably become qualified by training, education or experience].
The Change of Definition is a crucial time for the insurer. This shift in definition makes it more difficult to stay on benefits, and many LTD claims are denied at this stage. You might notice your insurer has scheduled a medical assessment or may be pushing you to return to work around the Change of Definition period. This is because a denial at the Change of Definition is very common. Insurers use the broader definition to their advantage in trying to justify denying your entitlement to ongoing benefits.
LTD claim denied after the change of definition? Here’s What to Do
A denial at the Change of Definition is a major turning point and is one of the most common reasons disability benefits are cut off. When your LTD claim is denied after the Change of Definition, it’s time to speak to a disability lawyer. The denial letters will have an option to appeal the insurers’ decision. However, it is important to note that the LTD appeal decisions are usually determined by the same case manager who denied your claim in the first place, thus making the chances of a successful appeal very slim.
A disability lawyer can challenge the Change of Definition denial through our legal system. A lawsuit might be intimidating at first but hiring an experienced disability lawyer to take the lead and help navigate you through the process is invaluable.
Speak to a Disability Insurance Lawyer
If your long-term disability claim is denied, it’s time to speak with a disability insurance lawyer. By challenging the denial, you may be able to get a reinstatement of benefits.
At Whitten & Lublin, we offer free disability consultations and have extensive experience with both short- and long-term disability claims. Call 416-640-2667 or contact us online to take control of your rights.
Author – Aman Chaggar
