Disability insurance companies deny and terminate claims as a matter of doing business, often to perform for Wall Street investors, but when it is your claim, it doesn’t feel like business as usual. It feels personal; it feels abrupt; it feels confusing; and it feels unjustified. Many claimants who have been receiving benefits are surprised to learn that their coverage can be terminated even when their medical condition has not improved.
A common explanation offered by insurers is that the claimant can still perform the material duties of their occupation, that the medical evidence is insufficient, or that the claimant has transferable skills that allow for alternative employment. While these arguments are familiar, they often surface most aggressively at a specific turning point in long-term disability claims.
That turning point is the transition from “own occupation” to “any occupation.”
The 24-Month Rule Under ERISA Policies
Most group disability policies governed by ERISA include a built-in change in the definition of disability after a set period, typically 24 months. During the initial period, a claimant is considered disabled if they are unable to perform the material duties of their “own occupation” (own occ).
After 24 months, the definition broadens – not favorably to the insured. The claimant must now demonstrate that they are unable to perform the duties of “any occupation” (any occ) for which they are reasonably suited by education, training, or experience.
This shift is not merely technical. It is often the basis for terminating benefits – despite no change in condition, and often despite Social Security awarding disability benefits.
Importantly, the transition occurs regardless of whether the claimant’s medical condition has changed. A person may be just as impaired at month 25 as they were at month 12. The difference lies entirely in how the policy defines disability.
What “Any Occupation” Really Means
The phrase “any occupation” sounds absolute, but in practice, it is subject to interpretation. Insurers often argue that if a claimant can perform even sedentary or part-time work, they no longer qualify for benefits.
In theory, the analysis should consider whether the alternative occupation is suitable in light of the claimant’s background and whether it provides a reasonable level of income. In practice, however, insurers rely on generalized job classifications and broad vocational assumptions.
This creates a significant hurdle for claimants. Jobs that exist in theory may not exist in reality for a person with specific limitations. Likewise, a role that appears suitable on paper may be incompatible with the claimant’s actual functional capacity.
Why Private “Own Occupation” Policies Are Different
Private or individual long term disability policies typically provide stronger protection. These policies insure a claimant’s ability to perform the material duties of their specific occupation, particularly when that occupation requires specialized training or advanced education.
For professionals such as physicians, dentists, and attorneys, this distinction is critical. The inability to perform highly specialized tasks should qualify as a disability, even if the individual could theoretically perform other types of work.
However, these claims are often subject to intense scrutiny. Because the potential benefits are substantial, insurers have a financial incentive to closely examine and challenge these claims.
Our firm has represented many professionals whose valid claims were denied despite clear medical support. The value of the policy itself is driving the insurer’s decision-making process.
How Insurance Companies Evaluate Risk and Deny Claims
Insurance companies operate as businesses grounded in risk assessment and profitability. Their decisions are informed by actuarial models that evaluate a range of factors, including:
- Policy pricing and structure
- The age and occupation of the insured
- The likelihood and duration of disability
- Economic conditions such as interest rates and market performance
- The probability that a claimant will appeal a denial.
Claims departments are structured to manage financial exposure. While insurers are contractually obligated to evaluate claims in good faith, their internal processes are designed to control payouts and protect margins. Understanding this framework helps explain why denials are common, particularly at key transition points like the shift to “any occupation.”
The Importance of Accurate Occupational Definitions
One of the most contested aspects of a disability claim is the definition of the claimant’s occupation. Insurers often attempt to redefine a job in broader or more generic terms to support a denial. Often, they rely upon outdated source materials – such as the Dictionary of Occupational Titles (DOT), a resource not updated in decades.
Consider the example of a chiropractor who owns a practice. Even if the chiropractor can no longer perform hands-on patient care, the insurer may argue that the claimant can still function as a business owner or manager. If the practice sells nutritional supplements or has employees or subcontractors offering related services, the insurance company will reframing the occupation and argue the chiropractor has an income stream and therefore is not disabled.
This type of analysis often overlooks the practical realities of the profession. Ownership does not eliminate the physical demands of patient care, nor does it guarantee meaningful income in the absence of active participation.
A precise and well-documented occupational description is therefore essential in any disability claim.
Flawed Vocational Assessments and Outdated Job Data
Vocational evaluations play a central role in “any occupation” determinations, but they are not always reliable. Insurers may rely on outdated job descriptions or databases that fail to reflect current workplace demands.
In one recent matter, Newfield Law Group overturned a denial by New York Life on appeal where the insurer relied on an obsolete description of a regional sales manager’s role. The actual position required extensive travel, continuous client engagement, and active management of a multi-state team operating under demanding performance expectations.
The insurer’s characterization of the job as primarily sedentary was inconsistent with reality. Once the true scope of the position was established, the denial could not be sustained.
Such discrepancies are not unusual. They highlight the importance of challenging vocational evidence rather than accepting it at face value.
Medical Evidence and the Myth of “Independent” Reviews
Medical support is the foundation of any disability claim, yet it is frequently disputed. Insurers often argue that the medical record does not substantiate the claimed limitations, even when treating physicians provide consistent and detailed opinions.
In many cases, insurers rely on internal medical reviewers or third-party vendors to assess the claim. These reviewers frequently do not examine the claimant in person and base their conclusions on a paper review of the file. They often challenge the treating physician opinion.
So-called independent medical examinations raise additional concerns. These evaluations are arranged and paid for by the insurer, and the selection of the examiner is not neutral. If an opinion does not support the insurer’s position, another evaluation may be pursued.
This creates an uneven playing field for claimants. This is another reason why having an experienced long term disability attorney is so important to getting claims paid and secured for future payments.
Surveillance and Social Media: Context Matters
Surveillance is a common tool in disability claim investigations. Insurers may conduct video surveillance or monitor a claimant’s social media activity in an effort to identify inconsistencies.
While such evidence can be relevant, it is deliberately misinterpreted. A brief period of activity may be presented as evidence of sustained functional ability. For example, a claimant who leaves home for a medical appointment on a rare, good day may be portrayed as capable of regular employment.
This type of reasoning ignores the fluctuating nature of many medical conditions. Disability is not defined by isolated moments of activity, but by the ability to perform work consistently and reliably.
The Role of Legal Representation in Disability Claims
In both “own occupation” and “any occupation” disputes, the outcome often depends on how the claim is developed and presented. This includes assembling medical evidence, documenting occupational duties, and challenging flawed vocational or medical opinions.
The process is particularly complex under ERISA, where procedural rules limit the evidence that can be introduced after an initial denial. A well-prepared administrative record is essential.
Experienced counsel can identify weaknesses in the insurer’s analysis and ensure that the claim is supported by comprehensive and persuasive evidence.
Protecting Your Right to Benefits
Long-term disability claims are governed by detailed policy language and shaped by strategic claims handling practices. The transition from “own occupation” to “any occupation” is one of the most significant points in the life of a claim and a frequent basis for denial.
While the system may not always operate in a manner that feels fair, claimants are not without options. A thoughtful and informed response can make a meaningful difference.
Protecting your right to benefits requires more than submitting a claim. It requires a clear understanding of the policy, careful documentation, and, in many cases, a willingness to challenge the insurer’s conclusions.
