Disability Insurance: Restrictions, Limitations & Considerations

Determining disability insurance benefits can be difficult – especially when a significant amount of time has gone by and the disabled person can return to work, but not in the same occupation. When that happens, it’s important to look at his or her restrictions and limitations – as well as considerations regarding other fields of possible employment.

Restrictions & Limitations

We asked Bob Scott, a California attorney and partner with the Advocate Law Group, to explain how disability insurance companies view restrictions and limitations. He told us:

If you have a policy that shifts the definition to any occupation, usually after two years, then you look at your training, education and experience throughout your life, apply those same restrictions and limitations and say, ‘Can you work in any occupation based on your training, education, experience – again, with reasonable continuity, 40 hours a week and in the real world?’

By that, I mean that you have to be able to find an employer that would hire you, and as the case law says, it’s not some fanciful occupation that somebody in the remote rehab section of the insurance company thinks you might be able to get a job.

Now remember, this is in an occupation you’ve never worked at before – so, it’s important to have spoken with someone who has said, ‘I would hire the person with these restrictions even through they’ve never worked in this occupation.’ It’s really a much higher burden.

Considerations

Something else that must be considered is known as station in life, according to Scott. He explained, “Station in life would mean that we’re not going to ask somebody to take a 30 percent or more drop in pay just so that the disability carrier doesn’t have to live up to its promise. So, putting that in context, we wouldn’t ask an executive to work as a ticket-taker at LAX when you leave the parking lot.”

The law; and how it’s ignored

All of the above criteria are the law, according to Scott. “It’s what I get at jury instructions. It’s what the California Insurance Commissioner has imposed on these companies when they have failed to apply this rule, and that’s the law that has to be applied in any given setting going forward.”

That being said, Scott was quick to point out that insurance carriers don’t follow that law. He told us, “When I fly out to take depositions of these insurance carriers, they don’t even know what I’m talking about. They have heard none of the words that I’ve just said ever said to them in training, yet they are interpreting disability policies for individuals in California day after day. That’s wrong, and not only is that an actionable wrong if they deny your benefits, it’s also something that should be directed to the Insurance Commissioner of California by filing a complaint saying that, ‘They denied my claim, and I don’t think they’re following their own rules.’”

If your disability insurance company has denied your valid benefits, contact an attorney whose practice focuses in disability law to discuss your situation. To speak with a qualified disability insurance attorney, please click here. Consultations are free, without obligation and are strictly confidential.

Case Studies: Disability Insurance Considerations and Limitations

Case Study 1: Bob’s Occupational Transition

Bob, a disabled individual, had a disability insurance policy that shifted the definition of disability to any occupation after two years. He could not return to his previous occupation but had the potential to work in a different field.

Bob’s attorney, Bob Scott, explains the importance of assessing Bob’s restrictions and limitations and finding an alternative occupation that aligns with his training, education, and experience.

Case Study 2: Station in Life Consideration

Scott further highlights the concept of “station in life.” He emphasizes that disabled individuals should not be expected to accept a significant drop in pay or take on menial jobs that do not align with their qualifications.

This demonstrates the relevance of considering an individual’s previous employment status and maintaining a reasonable standard of living when evaluating disability insurance benefits.

Case Study 3: Insurance Carriers’ Compliance With the Law

Scott reveals that disability insurance carriers often fail to comply with the law and appropriate standards when assessing disability claims.

Despite established legal criteria, insurance carriers may interpret policies incorrectly or disregard the rights of policyholders. This emphasizes the importance of seeking legal representation and filing complaints with insurance commissioners in such situations.