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What Does a “Change of Definition” Mean in Long-Term Disability Claims?

Change of Definition and Long-Term Disability Benefits

Long-term disability (LTD) benefits are a lifeline for individuals who are unable to work due to injury or illness. These benefits provide financial support to help cover living expenses and medical costs during a period of incapacity that prevents an individual from working. Over time, recipients of LTD benefits may encounter challenges if their insurance policy includes a “change of definition” provision.

Change of Definition Provisions

A “change of definition” provision is a clause commonly found in LTD insurance policies. Essentially, it means that the criteria for determining disability, or “total disability,” may change after a certain period. Initially, to qualify for benefits, an individual must demonstrate that they are unable to perform the duties of their own occupation, referred to as an “Own Occupation Test.”

However, after the specified period, typically two years, the definition of total disability may shift to require proof that the LTD claimant is unable to engage in any gainful occupation for which they are reasonably suited by education, training, or experience. This test is referred to as the “Any Occupation” test— essentially expanding the definition of disability from their specific job to all other forms of employment. Read your insurance policy to familiarize yourself with when the test for your disability benefits shifts from one test to the other, and how your policy defines each. Some policies only have a “Any Occupation” definition.

The Role of Medical Assessments in Shaping Decisions

Medical assessments play a crucial role in the LTD claims process, particularly when it comes to evaluating disability under a change of definition provision. Insurance companies may require claimants to undergo independent medical examinations (IMEs) conducted by healthcare professionals selected by the insurer. These examinations are meant to be objective and should be performed by a third-party.

These assessments vary case to case, and aim to assess the claimant’s current medical condition, functional limitations, and ability to work. Though it’s easy to be skeptical of these evaluations because they’re initiated by the insurer, it’s important for claimants to cooperate with them fully because resistance can be framed as a breach of one’s legal duties per their insurance policy and could result in a denial of disability benefits.

Just as it’s important to familiarize yourself with the details of your insurance policy, it’s equally important to take meticulous notes during an IME. Make sure to get the name of the professional performing the IME, what was discussed and asked of you, and how long the assessment took. Later, you are entitled to asking for your own copy of the IME report. Be prepared for the IME report to contradict the advice of your own personal medical team— arguing that you are in fact fit to return to work.

Challenges and Disputes

Navigating a change of definition provision can be complex and challenging for individuals seeking LTD benefits. Disputes often arise when insurance companies interpret the change of definition criteria differently from claimants or deny benefits based on their assessment of the claimant’s ability to work. Claimants may find themselves facing termination or a reduction of their benefits if they are deemed capable of performing other kinds of jobs, even if those occupations are significantly different from their previous work.

If you find yourself in this situation following a change of definition and IME report, you are entitled to having your own medical team prepare a report in response. Comments from your general practitioner or any specialists you may be seeing that reinforce the case for your disability can be presented to your insurer to dispute their findings.

How a Disability Lawyer Can Help

Beyond disputing the insurance company’s findings in an IME, seeking the assistance of a disability lawyer is crucial for individuals facing challenges related to change of definition provisions in LTD claims. A knowledgeable lawyer can provide invaluable support throughout the claims process, from initial application to appeals and litigation if necessary. Preszler Injury Lawyer’s team of disability lawyers can help gather and present compelling medical evidence, challenge adverse decisions by insurance companies, and advocate for the rights and interests of the claimant.

Understanding the implications of a “change of definition” in long-term disability claims is essential for individuals relying on LTD benefits for financial support. Being aware of the provisions in your insurance policies and seeking legal guidance when needed, you can better navigate the complexities of the claims process and protect your entitlement to the benefits you deserve.

If you or someone you know is experiencing an issue with a long-term disability claim, Preszler Injury Lawyers are here to help.

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