Bryant Legal Group’s disability attorneys take a proactive approach to insurance claims. We help professionals at every stage of their journey:
Private disability insurance policies vary significantly from policy-to-policy, and so too do the coverage exclusions that apply to insureds.
Whether certain coverage exclusions apply to your policy — and the limitations imposed by those exclusions — is often heavily dependent on how “premium” the disability insurance policy is. More expensive policies tend to feature fewer limitations and more generous benefits.
Despite these variations, there are certain exclusions that are more commonly encountered than others in the disability insurance context. These include, but are not necessarily limited, to exclusions that disqualify coverage to those who have been:
Insurers must come up with some justification for denying your disability benefits claim — if their justification has no reasonable basis, then you should appeal the denial or pursue a lawsuit to recover your benefits.
Common justifications for a claim denial include:
Definitions of “disability” are determined by the disability insurance plan or policy. Policies tend to define disability into three fundamentally different categories: specialty specific own-occupation, own-occupation, and any-occupation.
Specialty Specific Own-Occupation
If your insurance policy includes a specialty specific own-occupation definition of disability, then you will be entitled to benefits if you can prove that your condition renders you incapable of substantially performing the primary duties of your own occupation in the specialty in which you perform it.
For example, if you work as a trial attorney, but your disability has damaged your cognitive abilities, then you may be incapable of meeting the cognitive demands required of a trial attorney and as a result should be entitled to benefits under the policy.
If your insurance policy includes an own-occupation definition of disability, then you will be entitled to benefits if you can prove that your condition renders you incapable of substantially performing the primary duties of your current occupation. For example, if you work as a financial analyst, but your disability has damaged your attention span and your ability to remain on-task for more than 10 minutes at a time, then you may be incapable of performing the complex, hourlong analyses necessary for you to perform your job as a financial analyst.
Oftentimes, insurers attempt to deny benefits in the own-occupation context by arguing that the duties of your current occupation can be different, and that the duties of your current occupation are not indicative of the “norm” in the industry.
If your insurance policy includes an any-occupation definition of disability, then you will only be entitled to benefits if you can prove that your condition renders you incapable of substantially performing the primary duties of any other condition for which you are reasonably qualified (and that constitutes “gainful employment’). This is a very strict definition of disability and can require a nuanced approach to overcome.
Yes, absolutely — in fact, concern over plan mismanagement by fiduciaries is what led to the enactment of ERISA in the first place. ERISA fiduciaries have strict duties to act in the best interest of plan participants. Failure to do so could expose them to substantial civil liability under ERISA.
All insurance claimants — disability claimants included — have a duty to mitigate their various losses. The duty to mitigate generally entails the exertion of “reasonable effort” towards the minimization of your losses.
In laymen’s terms, this means attending your rehabilitation sessions, following through with treatment (by attending appointments), being consistent about taking your medication, and more. The insurer is not required to pay full benefits a disability that was exacerbated by the claimant’s own failure to act reasonably. If you fail to mitigate, then the insurer may have a reasonable basis to either deny your claim or undercut your benefits significantly.
Additionally, most disability insurance policies specifically require that you receive appropriate ongoing medical care; failing to do so, may be a separate reason for an insurer to deny your claim.
The consequences of lying — or otherwise misrepresenting the details reported in your original application for disability insurance coverage — vary depending on the nature of the misrepresentation.
In Illinois, you may still be entitled to receive disability benefits, even if you misrepresented certain facts on your original application, so long as those facts were not: 1) intended to deceive the insurer, and 2) material to the disability coverage.
For example, if you simply forgot to write about some minor health condition, the insurer cannot use that as justification for a denial (or rescinded coverage). Further, if the health condition is unrelated to the disability coverage — in other words, if they would have still extended coverage to you had you no misrepresented the facts — then the insurer is required to pay out benefits for a legitimate disability claim.
It’s worth noting, however, that the insurer may be entitled to payments to cover any difference that there would have been to the insurance premium.
You can — and likely should — challenge the insurer’s denial of your disability claim, so long as the claim is otherwise legitimate.
In Illinois (and in other jurisdictions), whenever there is genuine ambiguity in the language of an insurance exclusion clause, the courts are required to strictly construe that ambiguity in favor of the policyholder. Given the fact that courts strictly construe ambiguity in favor of the policyholder and against the interests of the insurer, your insurer is likely to argue that there is no ambiguity.
That being the case, it’s important to work with one of our Chicago disability claim lawyers who has experience handling such disputes — he or she will have to gather and introduce outside evidence that can be used to support your “ambiguity” argument.
Get the answers and insight you deserve. Our experienced disability insurance lawyers can evaluate your claim and help you understand all your legal options.