It has become more common for high-wage earners to purchase their own private disability insurance policies directly from insurance companies. Doctors and other professionals make this investment as a way of protecting their ability to perform their highly specialized, lucrative occupations. Some corporations also purchase private disability insurance coverage for high-level executives.

Private disability insurance differs from employer sponsored ERISA group plans in several important ways:

  • Policy agreements are private contracts, regulated by the states and subject to a standard judicial process.
  • A private disability or health insurance company that has denied your claim can be forced to substantiate its reasons for denying the claim in court.
  • Time limits and deadlines for contesting or appealing decisions are not as strict or arbitrary as they are in ERISA claims.
  • Courts interpret ambiguous, unclear language in private disability insurance contracts in favor of the person affected.

Disputes over a person’s right to benefits under private, individual disability insurance policy often involve interpretation of the policy language. For example, consider a surgeon who develops a hand ailment that prevents him or her from performing surgery. This surgeon anticipates receiving benefits, but the private health insurance company argues that he or she can earn income by doing something other than surgery, such as performing exams.

Such a case requires an experienced disability claims attorney who can successfully document the nature and extent of the injury or incapacity, demonstrating that the disabled person’s “same occupation coverage” applies to this situation. The case may require exploration of the material and substantial duties of the occupation, as well as extensive use of medical records and Social Security files.

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