A guide to decoding long-term disability language so you can protect your benefits.
LTD policies are full of legal and insurance jargon. This language may seem innocuous at first, but it can significantly impact whether your claim is approved, denied, or terminated later. Knowing the most important keywords in your policy can help you navigate the system more confidently, avoid costly misunderstandings, and better advocate for your rights. Here’s a breakdown of some of the most critical terms you’re likely to encounter and what they mean in practice.
Disability (as Defined by the Policy)
Every LTD policy has its definition of “disability,” and it’s not always what claimants assume. Some policies require total inability to work, while others recognize partial or residual disability. The definition may change over time (e.g., from “own occupation” to “any occupation”), and it’s this definition—not your doctor’s opinion—that ultimately determines whether you qualify. Reading the specific language is essential, as even a single word, such as “and” versus “or,” can make a meaningful difference.
Residual Disability
This refers to a condition where you’re not disabled but have lost the ability to perform part of your job or earn your previous income. Some policies offer partial benefits for residual disability, which can help support claimants during phased returns to work. However, this provision is only available if explicitly included in the policy, and the income thresholds and duties must be documented precisely.
Own Occupation vs. Any Occupation
These definitions shape how your disability is evaluated. Own occupation means you’re considered disabled if you can’t perform the duties of the specific job you had when you became disabled. Any occupation means you’re only considered disabled if you’re unable to perform any job—not just your prior role—based on your training, education, and experience.
Many policies shift from “own occ” to “any occ” after 24 months, making it harder to keep benefits. Even if your condition hasn’t improved, this redefinition can lead to termination unless your doctors document how your disability affects all forms of work.
Elimination Period
Also known as the waiting period, this is the number of days (usually 90 or 180) you must be continuously disabled before LTD benefits begin. During this time, you may rely on sick leave, short-term disability, or savings. Any break in care or return to work during the elimination period can reset the clock, so continuous documentation and treatment are critical.
Gainful Employment
Often defined as work that provides earnings equal to a certain percentage of your pre-disability income. Some policies also tie it to jobs that match your education and skills. The term is subjective and often used by insurers to argue that you’re capable of low-paying or part-time work, even if it’s not realistically sustainable for you.
Material and Substantial Duties
This phrase refers to the core tasks of your occupation. You may still be able to perform some aspects of your job, but if you can’t perform the material and substantial duties, you could qualify as disabled. Insurers may try to cherry-pick job duties to claim you’re capable of working, so having clear, functional medical documentation tied to these duties is critical.
Regular Care of a Physician
Most policies require you to be under the regular care of a doctor. But what qualifies as “regular” can be vague.
This language is often used to deny claims when there are gaps in treatment or if the insurer disagrees with the type of specialist you’re seeing. Keeping up consistent, appropriate care is essential to meet this requirement.
Independent Medical Examination (IME)
An exam requested by the insurer, typically conducted by a third-party physician chosen by them. Although it’s called “independent,” the doctor is hired and paid by the insurance company, and these exams often favor the insurer’s perspective. The IME report can be used to terminate benefits, so be prepared, consistent, and honest during the exam and follow up immediately if the report misrepresents your condition.
Pre-Existing Condition
This clause limits coverage for any condition you were treated for (or had symptoms of) during a specific “look-back” period, usually 3–12 months before coverage began. Even if your current condition is new or has worsened, insurers may use this clause to deny your claim if there’s any link to earlier records.
Maximum Benefit Period
This defines how long you can receive benefits, typically until age 65, but sometimes for a much shorter period, depending on the condition. Some policies limit benefits for mental health or substance use disorders to 24 months, even if the condition is chronic. Be aware of these caps early on so you can plan your treatment, documentation, and potential appeal strategy.
Offset or Other Income Benefits
Most LTD policies allow your insurer to reduce your benefit by amounts you receive from other sources, like Social Security Disability Insurance (SSDI), workers’ comp, or state disability. This can dramatically lower your monthly payment and create confusion if you receive back pay from SSDI or a lump-sum workers’ comp settlement. It’s crucial to understand how offsets are calculated to avoid overpayments.
Proof of Loss
This refers to the documentation you must submit to support your claim—medical records, test results, attending physician statements, and functional assessments. The burden is on the claimant to prove disability, not the insurer to disprove it. If your proof of loss is deemed insufficient, the claim can be delayed, denied, or discontinued. Detailed, timely, and consistent documentation is essential throughout the life of the claim.
Mental/Nervous Limitation Clause
Many policies include a cap—often 24 months—on benefits for disabilities stemming from mental health conditions (e.g., depression, anxiety, PTSD). Unless the condition qualifies as “severe and persistent,” benefits may be cut off at the 2-year mark, even if you remain unable to work. Knowing whether your policy includes this clause—and how your diagnosis is categorized—is vital for long-term planning and appeals.
Final Thoughts: Read the Fine Print. Then Read It Again.
The language in your LTD policy isn’t just legalese—it determines the outcome of your claim. By understanding how key terms are used (and sometimes misused), you’ll be better equipped to meet your policy’s requirements, avoid common pitfalls, and push back when insurers try to reinterpret the rules. When in doubt, speak with an attorney who can help decode the contract and advocate on your behalf.