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What job are they looking at? ERISA and the “own occupation” policy

 

Your disability policy says that you are disable if you cannot perform the tasks needed for your “own occupation.”  But, when your long term disability claim is denied, the insurance company is not looking at what you do, but instead at your occupation as it allegedly exists in the “national economy.”  Can they do that?

The answer is ….. yes and no.

The insurance company can look to a generic version of your job (and consider that in the decision).  However, the insurance company or plan administrators act arbitrarily when relying on a general notion of a position, rather than applying the plan language to the actual duties of the job, to determine a claimant’s ability to work.  The issue is not whether you can do “sedentary,” “light” or even “heavy” work; rather, the most significant aspects of the actual occupation —  the one you do  —  should be considered.

In the Tenth Circuit (where Colorado is located), it is arbitrary and capricious to fail to evaluate the requirements of the Plaintiff’s actual job.  In Campbell v. Ball, et al.,  we successfully overturned a “generic own occupation” analysis on this basis.  See our Reported and Significant case page for more details.  This is not new law;  This very issue was addressed several years in the  Bishop case. There, the plaintiff was a technology consultant, “a position that required extensive travel,” and was seeking disability benefits. The insurance company refused to consider that travel as part of the job.  The Court held  —   as it did in our Campbell case  –   that it was arbitrary and capricious to ignore this travel requirement in deciding whether Mr. Bishop was disabled.

 

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