Your job title may reveal little about the physical and mental demands you face each day. In a long-term disability claim governed by the Employee Retirement Income Security Act (ERISA), understanding the role this plays can give you an idea of what to expect.
How insurers assess your occupation
During the early stage of many long-term disability claims, the plan asks whether you can perform your “own occupation.” This test commonly lasts for 24 months before shifting to “any occupation” suited to your education, training and experience.
However, “own occupation” may not refer to the specific position you held. The policy may instead focus on how that line of work is generally performed in the national economy, leaving out duties unique to your workplace.
Why your job duties matter
The same role can involve very different duties from one workplace to another. One store manager may work mainly at a desk, while another may unload freight, stock shelves and spend most of the day standing.
Those differences can affect how the insurer views your medical restrictions. If heavy lifting is not considered a material and substantial duty of your occupation, a related restriction may not satisfy the plan’s disability standard.
A written job description, a statement from your employer and a record of your daily physical and mental demands can help explain what the position requires. However, the policy determines whether the evaluation focuses on your specific position or how the occupation is generally performed in the national economy.
What occupational classifications mean
After identifying your occupation, a vocational reviewer assigns it an exertional level and a skill category. These classifications summarize the physical demands of the work and the abilities needed to perform it.
Some plans also require those jobs to pay a certain share of your former income. If the reviewer finds work that meets these terms, the insurer may use that finding to deny or end benefits.
ERISA often preempts claims under Louisiana laws governing insurer bad faith when they concern the denial of plan benefits. This can make the internal appeal a key opportunity to correct the vocational record before a court evaluates the dispute.
How the claim review process works
The process begins when you submit proof-of-loss forms, an attending physician’s statement and supporting records. The insurer generally has 45 days to respond, although two 30-day extensions may apply if it explains the delay.
If the insurer denies your claim, you generally have 180 days to file an administrative appeal. They then have 45 days to decide the appeal, with one more 45-day extension in rare cases. You generally may file a lawsuit after completing the plan’s internal review process. Courts often defer to the decision-maker when the plan grants discretion, which raises the stakes of what you submit during the claim and appeal.