What is my "Own Occupation"? The overwhelming majority of ERISA governed group disability policies provide benefits for a period of time normally lasting 12-24 months for one’s inability to perform the duties of their "Own Occupation." Although the actual policy language varies from insurance carrier to carrier, each insurance company will usually define Own Occupation to mean the duties of the occupation as is it found in the national economy and not the actual job duties you are performing for your employer. The insurance companies will in turn review your Own Occupation as it is found in either the Dictionary of Occupational Titles (DOT), O*Net or some other similar vocational resource. More often than not, many people who have had their claim for benefits denied argue that the insurance company did not consider their claim in light of the actual job duties. A recent court decision may give this argument more strength.
Actual Duties Must Be Considered
In a recent decision in Richard Sewell v. Lincoln Life & Annuity Company of New York (Lincoln), a New York federal court weighed in on what "own occupation" means under an ERISA governed disability policy. This lawsuit was not handled by our firm. The Court determined that Lincoln was obligated to consider the actual duties of Mr. Sewell’s occupation and that by simply reviewing his claim as to his ability to perform a "like level" job Lincoln abused its discretion. Specifically, the Court indicated that under Second Circuit law, a review of regular occupation requires consideration of, "a position of the same general character as the insured’s previous job, requiring similar skills and training, and involving comparable duties."
What are Actual Duties?
Prior to filing a claim for disability, Mr. Sewell was a general contractor, which was comparable to a Project Director as established by the DOT. The Court notes that under applicable law "regular occupation" is not defined so narrowly as to include only the characteristics of [a claimant’s] job, it must be defined as a position of the "same general character" as [a claimant’s] job." This is where the above mentioned DOT/O*Net classifications come into play. In having Mr. Sewell’s claim for benefits reviewed by two peer review doctors, Lincoln had the doctors review the claim and medical records based solely on the characterization of his occupation as a "light level job." The Court noted that Mr. Sewell’s disability is based on his inability to perform his "own occupation" and must not be evaluated on an "any occupation" standard as the Court states Lincoln did when reviewing his claim. In turn, The Court stated that all the ensuing conclusions and caveats of the opinions of the peer reviewing doctors were based solely on the ability to perform a light level occupation." The Court argued that by its nature, a "light level" classification is even more general than a DOT nationwide job classification and is therefore less reflective of Mr. Sewell’s own occupation and the main duties thereof and subsequently determined that "failure to consider Sewell’s regular occupation beyond labels of "light-level work” was arbitrary and capricious."
So Does This Mean The Insurance Company Will Consider The Duties In An Employer’s Job Description?
Unfortunately, for 99% of the disability policies out there, the answer is No. However, this case does serve as a step in the right direction to hold insurance companies accountable for the way they review the duties of an insured’s pre-disability occupation. I have long argued that if an insurance company wanted Own Occupation defined to mean the physical demand level associated to an occupation, then they should write it that way. Although being able to perform the actual physical demand level required of an occupation is a factor to be considered, the actual "duties" of an occupation often go well beyond that. If your claim for benefits has been denied or you have concerns as to how your insurance company is reviewing your claim for disability benefits, please feel free to contact Attorneys Dell and Schaefer for a free consultation at 1-800-828-7583 or visit us at