The claimant seeking long term disability benefits under your ERISA Plan was found to be disabled by the Social Security Administration.
Does that automatically mean the claimant is entitled to disability benefits under the ERISA Plan? No, but you must explain why you are taking a position different from the Social Security Administration. Met Life v. Glen, 554 U.S. 105 (2008) highlighted that claims administrators must reconcile the Social Security determination with their ultimate ERISA plan denial. In other words, you cannot ignore the decision, but you are not bound by it.
A great new blog post explains how disability findings by the Social Security Administration involve different evaluative criteria, and give lots of weight to a claimant’s subjective complaints. Avik Roy, on The Apothecary Blog, http://www.forbes.com/sites/aroy/2013/04/08/how-americans-game-the-200-billion-a-year-disability-industrial-complex/ explains:
“Congress has dramatically expanded the definition of who gets called ‘disabled.’”
Congress relaxed disability eligibility criteria, giving greater weight to an applicant’s own assessment of disability. In 1984, Congress unanimously passed the Social Security Disability Benefits Reform Act. The SSDBRA instructed the government to: (a) place greater weight on applicants’ own assessments of their disability, especially when it came to pain and discomfort; (b) replace the government’s medical assessments with those of the applicants’ own doctors; and (3) loosen the screening criteria for mental illness, among other things. “The overall effect was to create a giant loophole, by which an applicant’s subjective claim that he was in pain, or mentally incapacitated, would be enough to claim disability.”
Statistics prove that while “Americans may be gaining weight, they suffer from fewer disabling conditions than they did 40 years ago, thanks to advances in medical technology.” Yet a new investigation shows that compared to 50 years ago “diagnoses that lend themselves to subjective manipulation, like back pain and mental illness, have grown substantially.”
The economic incentive to apply for Social Security Disability is greater than ever. According to published research, “the incentive to apply for [disability insurance] will increase with the rising value of health insurance through Medicare.” The rising value of disability payments can “explain as much as 20 percent of the growth in [Social Security income] receipt.”
This can help reconcile why a finding of Social Security disability does not automatically render a claimant qualified to receive long term disability benefits under your ERISA plan.