Sep 16, 2025 - Disability Insurance by Seltzer & Associates
When you’ve invested time and resources to build your career, part of your success plan includes protecting yourself from foreseeable risks with insurance. You purchase car insurance with uninsured motorist coverage to protect you in case of a collision with an irresponsible driver. You purchase liability coverage for your property in case someone should allege that they were injured on your premises. And you purchase long-term disability insurance to protect you in case an injury or illness renders you unable to work.
The question is, work at what? If you have what is referred to as an “own occupation” insurance policy, that policy should pay benefits if you are not able to practice the profession you were engaged in at the onset of your disability. On the other hand, if you have an “any occupation” policy, then you would only receive benefits if you could prove that you’re unable to work at any gainful employment.
Most professionals recognize they need “own occupation” coverage and are willing to pay extra premiums for it. However, insurance companies have made changes in the way that they offer plans and write coverage terms. You might think that you’ve purchased a plan with “own occupation” coverage only to find out that the terms include numerous loopholes and exceptions that make it extremely difficult to satisfy the definition of disability and qualify for benefits. At Seltzer & Associates, we’ve seen the lengths insurance companies will go to in their efforts to avoid paying benefits, and we urge you to review the details of your policy very carefully to ensure that you have the coverage you need in times of crisis.
Applications and Marketing Materials Can Lead to Confusion
Though insurance companies market themselves as supportive partners, they are merely businesses operating to make a profit. They earn more money when they take in lots of premiums and pay few benefits. So insurers have become quite sophisticated in reducing their coverage while hiding the changes. They believe that most people don’t read or understand the terms of the actual disability insurance policy, but that responsible professionals will read an application and marketing materials to find the coverage they want.
So they design marketing language and applications to suggest that the policy riders they offer provide the coverage professionals are looking for. It is only when you read the fine print of the policy itself that you learn that the definitions aren’t what you expected or that there are so many exceptions that it might be impossible for anyone to qualify for benefits.
For instance, a disability policy might offer a “medical occupation definition of total disability” option. At first glance, that sounds like it should offer “own occupation” coverage. Many physicians, dentists, chiropractors, nurse anesthetists, and other medical professionals would be likely to click on this option and assume that they have coverage in case something happens to impair their ability to perform their profession responsibly.
However, if they ever needed to file a claim, they might find that billing codes from the last 12 months reveal that they engaged in some practice areas that don’t fall under the category of their current limitations and that, therefore, they are not considered to meet the definition of disability under the policy.
Understanding Own Occupation Coverage
Traditionally, own occupation coverage would provide benefits when a professional became unable to perform one or more of the principal duties of their occupation. This type of policy might specify the occupation, such as a medical or dental specialty.
Policyholders often believe that their policy covers them if they are unable to practice the profession they engaged in at the time they purchased the policy, or the occupation for which they have been trained. Insurance companies view coverage and the policyholder’s role differently. For instance, the insurer might consider that the head of a surgery practice spends considerable amounts of time engaging in administrative or executive functions, and that if a hand or back injury prevented that policy holder from treating patients, the policy holder would still be able to perform many other tasks that were material and substantial parts of their role in the practice. Therefore, in the insurance company’s eyes, there is no eligibility for disability benefits.
It is important to analyze the definitions, exclusions, and requirements in the policy carefully to understand when disability benefits should be provided. If a policyholder is mistaken about the scope of coverage purchased, they must, unfortunately, bear the burden. However, when a good case can be made that the disability should be covered under the terms of the policy, then it makes sense to take steps to dispute the insurance company’s interpretation. A Philadelphia long-term disability appeal lawyer at Seltzer & Associates could negotiate a resolution or handle an internal review. If necessary, we understand how to succeed with a lawsuit to persuade the insurance company to honor its obligations under the policy.
How Can You Tell What Should Be Covered Under Your Disability Policy?
To understand when your coverage will apply and when it will not, you need to comb through the provisions and apply standing interpretations to the terms of art contained in the policy. This can be difficult to do accurately unless you’ve had considerable experience interpreting disability insurance policies.
At Seltzer Legal Associates, we focus our practice on resolving insurance disputes and helping professionals recover the benefits they are entitled to under their policies. We are intimately familiar with policy terms, and if you contact our team, we would be happy to review the details of your policy with you to help you assess whether you have the coverage you need to protect yourself.
Additional Terms to Consider
In addition to considering whether you are eligible to receive benefits if you are unable to practice the profession you were exercising at the time your disability began, you also need to look at some additional terms in your policy. First, determine whether the policy coverage changes or discontinues after a set period of time. For instance, you may be eligible to receive benefits for two years if you’re unable to work at your own occupation, and then after two years, you will be reassessed and must prove that you are unable to work at any occupation in order to continue receiving benefits.
It is important to see how your abilities will be assessed under the policies and the process for appealing any unfavorable decisions or disputes. Insurance companies can be very aggressive in challenging the disabilities of professionals, so it can be very helpful to work with an experienced attorney who knows the arguments and evidence insurance companies find persuasive.
Get Help Understanding and Enforcing Your Rights Under Your Disability Insurance Policy
Buying insurance can sometimes feel like buying a safety net full of holes. One wrong step and your protection disappears. We don’t think that’s good business, and we know that insurance companies often issue decisions that violate their contractual obligations. When that happens, a knowledgeable Philadelphia insurance bad faith attorney can hold them accountable.
If you would like assistance filing a claim for disability benefits, appealing a claim denial, or simply understanding the terms of your policy, we invite you to schedule a free confidential consultation by calling 888-699-4222 or contacting us online. We are based in Philadelphia but provide assistance to clients throughout the U.S.