Long Term Disability Insurance and “Own Occupation Duration”

It's my understanding that the "Own Occupation" coverage is no longer offered by ANY insurance carrier. I was lucky enough to stumble into purchasing a "Own Occupation" plan back in the late 80s; so when Lupus kicked me out of work in the early 00's I was covered. I did have to push a bit to collect benefits, and my (excellent) disability attorney at the time is the one who told me such policies were no longer available.

At the time I also went thru the Social Security Disability process and expected to be turned down, as I figured they'd tell me to go sell hamburgers or something. IE, "Any Occupation". It took a while, but after completing all applications, appeals, etc once I got before the Judge he quickly approved my disability without any argument.

Both my private LTD and SSD required Drs statements every once in a while to continue getting benefits -- they were simple multiple choice forms for my main Dr and I never received any push back that I should return to work or find other work.

So, that isn't the same as your situation and certainly doesn't answer your question, but I thought maybe sharing how it's worked for me might give you some clues as to how it MIGHT work in real life.

Best wishes,

Thank you jnf and lynnwood.

Another question i have is if Social Security determines i am disabled under their compassionate allowances provisions does that affect the long term disability decision from my employers ltd plan post 24 months?

Are the two determinations of disability independent or dependent?

So I am metastatic to the lungs, pretty rare, and it is a condition that seems to get greenlighted for ssdi benefits

https://secure.ssa.gov/poms.nsf/lnx/0423022282

“ Prostate Cancer – Hormone Refractory Disease occurs when the cancer is recurrent (comes back despite hormonal intervention) or the cancer has spread to the bone or visceral organs (visceral metastases) such as the liver and lungs.”

Is it reasonable for me to think that the ltd benefit from my work plan follows the determination from social security?

As Lynwood says, the determinations will be independent. However, your group coverage will probably be offset by any SSDI you receive based on the 60% factor of income factor. In other words, the 60% will be determined, then the SSDI benefit will be subtracted and the result is what you will receive from your group coverage. Your group coverage will undoubtedly contain a coordination of benefits provision. Rarely does one receive the full group benefit and the SSDI benefit. Most group coverage plans will require you to also apply for SSDI and I have seen some that will actually assist you in getting the benefit as it reduces their financial exposure.

Your group plan will be based on your inability to do your current job. It will not go into the same detail as to your condition that SS does regarding the Compassionate Determination process. It is normal that your group coverage requires you to disclose any and all disability income you are receiving from other sources for the same disability under the coordination of benefits provision.

For SSDI you have to be disabled and not working before you can effectively file. The first question asked is, are you currently working? If you answer yes, then that basically stops the process regardless of the health condition. The Compassionate Determination does not award benefits, rather it basically puts you at the front of the line and a benefit determination is made in months rather than years.

It sounds like you are full time employed now, so it would likely be premature to file a claim for benefits from either your employer or SS. If you are able to work, but are considering stopping in order to get disability benefits, I suggest you seek a great employment/benefits attorney for a professional assessment before taking action. In your case taking Lupron and Xtandi is most often tolerated well enough by most people that they can continue to work. That could work against you in seeking a benefit. Financially, you probably will not be in as good a position on disability as when you are employed as you lose all your employment benefits. So that is another consideration. I have known many men that qualify for the Compassionate Determination that do not seek SSDI and group benefits due to the financial aspects. So consider all these carefully.

Before hiring an attorney, read the policy you are currently covered by. It will be in your benefits portal. And you can request it in hard copy from either your employer or the insurance carrier. Of course all the specific information including statutes, regulations and methods are all on the SS website for SSDI and Compassionate Determination. In all it is not difficult reading. When you do search for an attorney make sure it is one that specializes in SSDI and employment benefits law and can demonstrate excellent experience. Don’t go to a general practitioner.

From a practical perspective, if you get SSDI it may help with the group insurance determination as the SSDI often reduces the group benefit significantly so they may have little to pay. This can help with the “any occupation” issue after the 24 months. I suggest you first determine your SSDI amount and compare that to the group coverage limit to see what the group coverage will actually pay. Also, reading the policy will define what the 60% is applied to as it usually excludes any kind of incentive, variable pay and non-cash benefits. It is not unusual to see a dollar limit as well, so it may not be a true 60% of total income. You only know this by reading the actual benefit definition.

I trust you have registered on the SS website so you can see your current Primary Insurance Amount (PIA). This is the projected retirement amount at your full retirement age and is the amount that your current SSDI would be. If you haven’t registered, it is easy to do so. And you mentioned Medicare, which you will be eligible for after 24 months on SSDI. You will have to pay the Part B premium, purchase a Medicare Supplement Plan and a Part D Prescription Drug Plan. And if you still have children under age 18, they will receive a benefit until age 18. Your wife may also receive a benefit, but will be subject to offsets based on any income she receives. Check all this out.

Most often, employment is technically terminated once disability pay starts putting you in a COBRA situation for your health insurance coverage. This lasts only 18 months and is quite expensive and leaves you with a 6 month gap which will have to be filled in by individual coverage, also expensive. And this would also apply to your wife. Your group life insurance will also go away after termination. Most plans allow for conversion to permanent coverage, but can be very expensive. With metastatic PCa and on SSDI, you will have a low probability of buying personal life insurance at standard rates, or even at all. So check out all these known and expected costs before making any decisions.

Lynwood, the SSDI does not get reduced, the group plan usually does by the SSDI, under the coordination of benefits provision found in most group plans. Remember, you have an individual plan and they often do not have a coordination of benefits provision, some do and some do not. Your experience with your individual plan should not be compared to the group plan that Stephen has. Apples and oranges.

Your comment about the cognitive is very true as disability isn’t limited to physical issues.

I deleted my post about the shrink as I am very depressed today that made me write something out of frustration.

Wings of Eagles said...
What is basic retirement age defined as these days???

It depends on when you were born. Full retirement benefits start at age 67 for me. Early retirement can happen anytime after age 62. Medicare is still age 65 unless you are determined to be disabled then you can qualify earlier.