{3:10 minutes to read} The phrases “legal disability” and “factual disability” are common jargon within the insurance industry.
It is often argued by insurance companies that loss of professional license or getting fired from your job is no basis for a disability claim because the disability was not caused by sickness or injury. For this reason, I view legal versus factual disability as an issue of causation, meaning what caused the disability – was the firing or loss of license caused by injury & sickness or not?
Case study: A healthcare professional is convicted of criminal conduct. As a result, he loses his professional license. During the process, he becomes clinically depressed and asserts that he is totally disabled. If he tries to claim benefits under his disability insurance policy, the insurance company will likely assert that his disability was caused by something other than a sickness or injury.
Which Came First: The Chicken or The Egg?
In the aforementioned scenario, the issue is whether or not the healthcare professional was disabled before he lost his license – or did he become disabled after the fact? If the disability occurred after the event that affected his ability to work, he may not be successful in his claim.
That example seems simple, but cases like these have the potential to become very complex.
Case study: Erica was terminated from her job for poor performance. She did not realize at the time that a sickness had caused her poor performance. She was eventually diagnosed with a chronic illness, which prompted her to realize that it was actually the effects of the illness that caused her to lose her job. In this case, a strong argument could be made in support of her claim.
The success of a person’s claim will center on key components, such as:
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- When the person sought medical treatment;
- When the person was diagnosed;
- The treatments the person has undergone; and
- The degree to which the person is currently disabled.
Note: Credibility is very important when determining legal versus factual disability. If someone has been fired or faced revocation of their professional license, there is going to be a question as to whether that person is telling the truth.
It is in the best interest of the claimants to consult with an attorney to discuss the viability of the claim before going forward.
Have you covered “all bases” in preparing your claim?
Evan S. Schwartz
Founder of Schwartz, Conroy & Hack
800-745-1755
ESS@schwartzlawpc.com