Disability insurance can mean either benefits through a private policy or disability payments through Social Security. For many professionals in high level occupations that means purchasing what is called an “own occupation” long term disability policy. Generally, an own occupation LTD policy allows a policy holder to receive benefits if he or she is unable to perform the material and substantial duties of their occupation. This is important because policy holders are often able to perform some jobs despite their condition, but are unable to perform the duties of their chosen occupation. In these situations, it is important to thoroughly review and understand the policy’s definitions as well as meet all plan requirements.
Oftentimes insurers will deny or cut off benefits which will require a policy holder to pursue the benefits through a federal court action. In one such case, a policy holder was the CEO of a major development company who filed an LTD claim for “medical depression.” The insurer paid the claim for a period of years before eventually terminating benefits based on several IME assessments that found the policy holder’s depression was in partial remission and that she had no objective limitations or skill deficits except her own subjective report that she did not feel confident enough to be a CEO. The court ultimately found for the policy holder and ordered the reinstatement of monthly benefits.
Factors supporting continuation of benefits:
· All of her treating physicians concluded she was unable to perform the substantial and material duties of her occupation as a CEO of a major development corporation.
· Policy holder was just shy of her 60th birthday when she initiated her claim and so per the policy, benefits were to be paid for life.
· Policy holder was more than a “garden-variety president and chief executive officer.” Instead, she was the CEO of a multi-million dollar company with several hundred employees and several ongoing ventures.
· Even IME Global Assessment of Functioning rating showed mild impairment.
· Plaintiff at all times was under the care and attendance of a physician for major depression.
· Insurer determined that the plaintiff was totally disabled as of the date of an IME report, but determined based also on the IME report that she would be fine to resume CEO duties in 6 months.
· Court rejected this assertion stating that such an assertion was based on the same type of subjective self-reporting that the insurer rejected.
The case is Kuhn v UnumProvident Corp, 2006 WL 2766163 (D Ariz, September 25, 2006).
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