Disability Insurance Denied

December 2, 2012 11:44 AM

Understanding my insurance company's decision to deny my Long Term Disability claim

This is the insurance company's rationale for denying me long term disability:
"The medical information indicates that you are not able to perform your duties as a Teacher because of the large class size your Employer required you to teach. However, the Occupational Analysis for a Teacher confirms that class size is not an Essential Duty of your Occupation.
As a result, the medical information submitted does not support that you were prevented from performing your Essential Duties of your Occupation as a Teacher. Therefore, you do not meet the definition of Disability."

I literally do not understand "...class size is not an Essential Duty of your Occupation." "Class size" isn't even a verb, how can it be a duty??

I don't know how to proceed with my appeal. Can anyone help me understand this?

posted by Kazimirovna to law & government (7 answers total)

That sounds like it means "Teaching large classes is not an Essential Duty of your Occupation". In other words, they think you could go and teach small classes instead.
posted by emilyw at 11:48 AM on December 2, 2012 [3 favorites]

Lawyer up, yo. This is what many lawyers do. Thankfully.
posted by Madamina at 11:53 AM on December 2, 2012 [1 favorite]

First: any disability claim should be made with the assistance and advocacy of a lawyer. Not only will that help your claim, but the lawyer will be able to explain to you what is going on during the process. (IANAL)

I literally do not understand "...class size is not an Essential Duty of your Occupation."

The job description of "teacher" does not require you to handle any specific class size. You can get another job as a "teacher" teaching smaller classes.

From an earlier AskMe of yours, you wrote that you received a diagnosis/solution from a health care professional of, "She may not work alone with more than 15 students at one time due to phobic reaction. She may teach in a small group or coteaching environment."

Long Term Disability means that you can NEVER work under any normal circumstances. You may have a disability that you cannot be "in charge of 25-30 kids by myself." But there are plenty of teaching jobs in which you don't have to be "in charge of 25-30 kids." So your insurer is saying that you should get one of those other teaching jobs.
posted by deanc at 11:55 AM on December 2, 2012 [5 favorites]

I take it as meaning that a disability claim is about your inability to work, not about your inability to work within the constraints of this specific job. So, as emilyw says, they're telling you you should change your working environment (either by negotiating a smaller class size, or by working elsewhere) rather than just quitting work altogether and living off the insurance payment.

So they're saying: "We will accept your disability claim if you are unable to perform some essential duty of your occupation as a teacher. Coping with a large class size is not an 'essential duty' of teachers in the way we have defined it, since it's possible for you to teach a smaller class".

I would imagine that what they're looking for is a specific condition that you would render you unable to teach at all (or, on preview, what deanc said)
posted by pipeski at 11:56 AM on December 2, 2012

Being unable to teach a large class doesn't mean that you are incapable of teaching at all. For example, you could coteach or teach a small class. That is what they are saying.
posted by SkylitDrawl at 12:29 PM on December 2, 2012

You might want your name removed from this askme, since it may eventually lead to a lawsuit.

My other advice is that, although you may not have a disability claim, you may have an Americans With Disabilities situation in that your employer would need to adapt your work environment (class size?) due to your disability, you might want to look into that possibility as well.
posted by HuronBob at 1:18 PM on December 2, 2012 [2 favorites]

What probably happened, as far as the weird language use goes, is that this was a form letter generated from inputs from a database. Or the person writing it just doesn't write well.

But yeah, they are denying it because it is not a long-term disability, as they define it. They most likely define it as unable to perform the duties of your *occupation* as opposed to your current job. You have not lost the ability to teach, only the ability to teach large numbers of students.

Another example: suppose I'm an accountant, and I ride the train to work. Now I've gone and lost my feet, and can no longer ride the train. This stops me from being able to do that job at that location, but I have not lost the ability to be an accountant. If I were a dog-walker, however, I probably would have a successful claim.

(As for anonymizing: once it is out there, it is out there. Publishing under your name, and then removing your name makes it look like you have something to hide. Do not do things like that without a lawyer's advice.)
posted by gjc at 1:56 PM on December 2, 2012