Every long term disability (“LTD’) policy has a definition of disability. If your definition changes after a period of time, the insurer will send you a letter warning you about definition change (“COD”) and advising you of the COD date.

If the LTD insurer accepts your claim, they have admitted that you satisfy the policy definition of disability. If your policy’s definition changes to a new definition of disability, they will perform a definition change assessment. The LTD insurer will determine if they agree that you satisfy the new definition. The new definition is usually harder to prove than the initial definition of disability.

Own Occupation Period/Definition:

After you have satisfied the waiting period or qualifying period, your LTD benefits will start.  Many LTD policies call that first period the “own occupation period”. During this period, you qualify for benefits if the insurer accepts that the information you have submitted in support of your claim proves that you are unable to perform your own occupation. The own occupation period may run for 24 months from the date your disability benefits are first paid. The date at the end of the 24 month period is called COD or definition change. While this is the most common own occupation period, other policies may have longer or shorter periods of own occupation benefits.

Any Occupation Period/Definition:

At COD, the insurer will continue to pay your LTD benefits if you satisfy the new definition of disability. That definition is often called “any occupation” or a “gainful” occupation. For example, you may only be entitled to LTD benefits if the medical information supports that you are unable to work at any occupation which you can perform based on your level of education, any training you have received and your work experience.

The Definition Change Assessment:

Most insurers will advise you of the definition of disability and the COD when your LTD claim is admitted. Over the course of your claim, they will usually remind you that they will continue to assess your claim and will make a determination at COD about whether your benefits will continue. As COD approaches, you may be asked to provide a statement or questionnaire which sets out a summary of your education, your prior employment and any other skills or experience you have which would be relevant to a determination of what other work you can do.

Another tool an insurer may use to assess your ability to perform another occupation is a transferrable skills analysis (“TSA”). The insurer may interview you in order for the TSA to be performed. The insurer may use an in-house program or an external company to assess what other occupations you may be able to perform. If your insurer advises you that it believes that you can perform another occupation, it is important to ask for a copy of the TSA and/or examples of those occupations. If the TSA did not consider the continuing restrictions or limitations caused by your disability or did not accurately consider your education and prior experience, the COD assessment is flawed. Further, if the income level they consider for the alternate occupations is too low, we can challenge the decision.

“Any occupation is not really any occupation”

Many policies will set out a threshold amount of income which qualifies as “any occupation”. For instance, your policy may say that if you cannot work at your own occupation but you can earn an income at another occupation which will earn you 60% or more of the monthly earnings of your own occupation, you do not satisfy the any occupation definition of disability. Not all policies specify a minimum or threshold income but generally if you can work at an occupation which will provide you with an income which is “commensurate” with your prior income in your own occupation, the insurer will probably terminate your benefits because it does not accept that you are disabled from any occupation.

Many people’s LTD benefits are terminated at COD and the insurer’s decision can be challenged. You should appeal the insurer’s decision or challenge the decision with a lawsuit if you cannot work in your own or any occupation due to your continuing disability. Sometimes the only thing that has changed at COD is the definition of disability. You continue to be disabled and should challenge the insurer’s assessment.

Conclusion:

Many people accept the insurer’s decision at COD. The insurer may have overestimated your education or transferrable skills or they may have made an unfair assessment of your continued symptoms. You should contact a lawyer with experience challenging definition change assessments and terminations of LTD benefits.

For advice please text 613-777-0992 or contact us through our website to schedule a meeting with one of our lawyers.  We provide a free consultation, in French or English, to ensure that your rights are protected.   In most cases, we can offer to represent you on a contingency fee basis.  This means that you do not pay legal fees unless you win or achieve a settlement on your case.