New ERISA Trend Alert: Using the Wrong Definition of Disability

This trick (or error) is showing up with increasing frequency. When you purchased your insurance disability policy (or when your employer did), they were essentially paying for a specific definition of disability. The term “disability,” or “disabled,”  is specifically, and carefully, defined in your contract. As such, that definition is of the utmost importance:  it determines everything in your claim. Now, I see a few claims a week in which the insurance company terminated benefits after reviewing the claim under the wrong definition of disability!

Whether this is by mistake or by design, is open to debate. Here is an example from a Hartford policy:  “Disability or Disabled means You are prevented from performing one or more of the Essential Duties of: 1) Your Occupation during the Elimination Period…”

In ERISA work, this is great contract language. It means that you are disabled if you can prove an inability to do only a single Essential Duty. This contract went further and defined “essential duty” to include the ability to work a 40 hour work week.

So, reading this language, I think there is no way this person can be denied with their disability. In the denial letter, they use the wrong definition of disability. This is what was written: “To meet the definition of disability above, you must be unable to perform the duties of your occupation.”  In mathematical terms, “the duties” ≠ “one or more duties.”

Here is why that incorrect definition changed the game. It means that to be disabled, the client had to be incapable of doing each and every job duty of her prior job. Her contract, however, entitled her to benefits if she couldn’t do just one job duty.  Using the wrong definition, the insurance company was able to say she wasn’t disabled.

Too many clients fall for this trick.  The advice is as follows: read your contract language, compare it to what’s written in any denial/termination letter.  Don’t take their word for it.

If you’ve received a denial letter, give us a call today and let us help.