This is the time of the year when many employers have their insurance open season, where employees are free to make changes to their existing insurance coverage. If you're considering adding that long-term disability coverage option to your existing insurance benefits, be careful to read the terms first and look for the words "gainful employment" or "gainful occupation." If you see them, you may want to skip that policy and look for another. This is what you should know.
The difference in terms matters.
The difference between "own occupation or employment" and "gainful occupation or employment" matters quite a bit when it comes to how likely that long-term disability policy is likely to pay out over time—or even at all. A policy that is written to cover you in the event that you aren't able to return to your own occupation or employment can be a real lifesaver if you happen to become disabled. However, many are written in much vaguer terms, using the "gainful occupation or employment standard." That means that the policy can deny you if you're capable of working even the most simple jobs—working as a door greeter at the local Walmart, for example.
Watch out for changes in clauses over time.
Some policies also change their terms over time. It isn't uncommon for a long-term disability policy to cover the first 2 years of the policy under the "own occupation" standard and then switch to the "gainful occupation" standard. If that happens, you could suddenly find your benefits under review and then cut off under the premise that there's some other job out there that you could be doing.
Look to see if the insurer gives itself the exclusive right to make all decisions.
Another tactic used by long-term disability insurers to avoid paying long claims is to give themselves the sole right to determine not only the meaning of the terms it uses but the fact surrounding the claim. Some providers have repeatedly used this particular clause to their advantage in order to cut off benefits as soon as the "gainful employment" clause kicks in and have even offered bonuses to adjudicators based on the number of cases they deny.
When an insurer gives itself the right to make the sole determination of facts in a claim, they can have a doctor look over your records, without ever examining you, and override your own doctor's opinion that you're unable to work.
Getting long-term disability is a smart decision for anybody who can afford it—but don't automatically go with the plan that's available through your employer unless you read the terms first and fully understand what they mean. If you want to stay out of litigation in the future, look for a policy that plays fair with its customers. If you're uncertain if a long-term disability policy is worth the premiums, consider having a lawyer like Scott E. Shaffman Attorney At Law review the policy before you sign up for it.Share