The issue of “any occupation investigations” seems to be coming up a lot lately, therefore, the subject warrants another post. Either claimants are not aware of what “any occ” means, or they allow the process to proceed from the insurance company’s point of view, both placing the claim potentially a risk. However, a well managed “any occupation investigation” by the claimant most often results favorably for the claimant.
Here are a few points about “Any Occupation” that most people do not know:
- Employer Group Plans do NOT insure employees’ jobs, only the occupation as defined in the national economy.
- Own occupation definitions can change into Any Occupation after 12, 24, 36, or 60 months with 24 being the most common.
- Employer Group Plans, as written, do not intend to pay claims beyond 24 months. The goal is to get everyone on SSDI in the first months and then deny further benefits, if they can.
- Internal any occ investigations operate under the GEIGO principle. (Garbage-in – Garbage-out) If the investigation is done before updating current medical restrictions and limitation, the results will be misleading and inaccurate.
- Insurance companies frequently ignore the issue of “indexed-pre-disability earnings” and the effects of inflation are omitted, and/or not documented. $1 can often push the results in favor of the claimant.
- Insurance companies may not conduct “any occ” investigations if it appears “gainful” will be an issue, or that medical information is so persuasive that results are obvious.
- Any occ investigations can be done between 9 -18 months of paid benefits for 24 month definition. 12-month any occ will begin right away after approval of the claim.
- Any occ investigations can be performed at any time while claims are still being paid.
- Any occ investigations are the last major opportunity to deny ERISA claims. DCS, Inc. has not had very many any occ investigations be favorable to insurers.
I think the important things for claimants to remember are the limitations of the Group product to begin with. Although most ERISA Plans will pay to age 65 or 67, it is not the intent of the employer, or the insurer by virtue of the Plan provisions themselves, to continue to pay claims to maximum duration.
Group Plans contain inherent potential limitations for payment including the any occ investigation, 24-month mental and nervous limitations, self-reported limitations, the inclusion of work incentives (WIP) to return to work, 3-5 year COLA periods, and most importantly, discretionary authority. These Plans are never intended to pay to maximum duration. The fact that some claimants ARE paid to maximum duration is a huge loss for the group insurer.
It is very important for ERISA claimants to ensure that all medical information is updated and sent to insurers as soon as it becomes known the “any occupation investigation” started. It is a process that should be managed with additional information to file in every case.
