Definition of Total Disability at Claim Time: Own Occ vs. Regular Occ

August 2, 2017

Provide expert advice about how Total Disability changes when a client adds an Own Occupation Rider to a Platinum Advantage policy. This article explains exactly when and why a client might need the Own Occupation Rider.

First, let's look at the base Platinum Advantage policy language:

According to the policy, Total Disability means that due to injury or sickness:

  • you are unable to perform the substantial and material duties of your regular occupation; and
  • you are not engaged in any other job or occupation for wage or profit; and
  • you are under the regular care of a physician appropriate for your injury or sickness.

When a client selects the Own Occupation Rider, the definition of Total Disability changes to remove the second bullet, “You are not engaged in any other job or occupation for wage or profit.” This means we may consider the insured totally disabled when injury or sickness makes them unable to perform the duties of their regular occupation even if they earn money in another occupation.

Both the Regular Occupation definition and the Own Occupation Rider state that physicians or dentists who have limited their practice to a single specialty recognized by the American Board of Medical Specialties, American Osteopathic Association Bureau of Osteopathic Specialists or American Dental Association will be considered totally disabled if they can't perform that specialty. With the Own Occupation Rider, this specialty language extends to trial attorneys as well.

With the Own Occupation Rider, if the insured works in another job — even just a different specialty — he or she could still be considered totally disabled, and may qualify for the full monthly benefit. Without the Own Occupation Rider, these medical or legal professionals may not be found disabled and benefits may not be paid.

A couple of key things to note:

  • Regular Occupation is the occupation or occupations in which the insured is regularly engaged at the time disability begins. This is not always the same as the insured’s work at the time of application.
  • The claims department may request comprehensive income documentation to understand the insured’s total income. However, only earnings from his or her occupation will apply when we determine the amount of benefits that will be paid.

If you have a question about claims, please send us a message by completing the message form. Be sure to select “Claims Questions” in the topic drop-down menu.

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