How Disability Insurance Definitions Determine Your Claim
The most important language in any disability insurance policy is the definition of "disability." "Own occupation" policies pay benefits if you cannot perform the duties of your specific occupation—a surgeon with hand tremors qualifies even if she could theoretically work as a medical consultant. "Any occupation" policies deny benefits if you can perform any job suited to your education and experience—a much higher bar. Most group long-term disability (LTD) policies transition from own-occupation to any-occupation after 24 months, producing a surge in claim denials at the two-year mark.
Common Denial Reasons and How to Challenge Them
Insurers frequently deny or terminate disability claims based on: independent medical examinations (IMEs) by company-hired physicians who opine you're not disabled; surveillance video purportedly showing activity inconsistent with claimed limitations; alleged failure to comply with treatment; insufficient objective medical evidence; or a determination that your symptoms are "subjective" (pain, fatigue, cognitive impairment) without sufficient clinical documentation.
Each denial reason requires a targeted response. IME findings are contested with your treating physician's contrary opinion and functional capacity evaluation results. Surveillance is challenged by contextualizing the activity (one good day doesn't represent full-time work capacity). Subjective symptom claims are strengthened with neuropsychological testing, pain specialist documentation, and detailed functional diaries.
ERISA: The Biggest Obstacle in Group LTD Claims
Most employer-sponsored disability plans are governed by ERISA. In ERISA cases, the court reviews the insurer's denial under an "abuse of discretion" standard when the plan grants the insurer discretionary authority—meaning the court will uphold the denial unless it was unreasonable, not just wrong. This makes the administrative appeal process critically important: all evidence and arguments must be submitted during the appeal, because you generally cannot submit new evidence in federal court. An ERISA attorney should be involved in the appeal process, not just after it fails.
Individual Disability Policies: Stronger Rights
Individually purchased disability policies (not employer group plans) are not governed by ERISA. You have full state court access, the right to a jury trial, and potentially bad faith remedies if the insurer acts unreasonably. Individual policies often provide stronger "own occupation" definitions and are worth fighting for aggressively. California, Florida, and several other states have particularly strong bad faith remedies for unreasonable individual disability claim denials.
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Frequently asked questions
What is an independent medical examination in a disability claim?
An IME is an examination by a physician selected and paid by the insurance company—not your doctor. Despite the "independent" label, IME physicians are often repeat contractors with financial incentive to produce insurer-favorable opinions. Your treating physician's opinion, developed over months of care, typically carries more weight with courts than a single-visit IME, especially when the IME physician didn't review all medical records.
How long do I have to appeal a disability insurance denial?
For ERISA-governed group plans, you typically have 180 days to file an administrative appeal after denial. For individual policies, state-law appeal deadlines and contract terms apply—usually 60–180 days. Missing the ERISA appeal deadline is extremely serious: it can bar you from federal court review of the decision. Consult an ERISA attorney as soon as you receive a denial.
Can I receive both Social Security disability and private disability benefits?
Yes, but group LTD policies typically have "offset" provisions reducing your LTD benefit by the amount you receive from Social Security Disability Insurance (SSDI). Most LTD insurers require you to apply for SSDI and may advance you LTD benefits while the SSDI claim is pending, then recover the offset when SSDI is awarded. SSDI approval can also strengthen your private disability claim by providing an independent finding of disability.