We all know that ERISA claim administrators must consider and weigh a claimant’s Social Security Administration (SSA) disability determination when deciding whether the claimant is “disabled.”
But what happens when the SSA’s favorable disability determination arrives after the Plan has denied the final appeal?
Do you have to reopen the claim to assess this new information? No.
Here’s the recent case of Hooks v Hartford Life and Accident Insurance Co., 2012 WL 5187780, (M.D. Ala. October 19, 2012)(Plan not obligated to reopen and consider SSA determination received after appeal denial) [PDF].
FACTS: Hooks sought disability benefits under the ERISA plan. Hartford provided benefits from June 22, 2009 to August 3, 2010, when it then concluded Hooks did not meet the definition of disability. Hooks appealed. Hartford denied the appeal on May 16, 2011.
On June 27, 2011, Hooks informed Hartford for the first time that the SSA had ruled that she was disabled. (The ruling had been issued June 2, 2011). Hooks demanded that Hartford reopen the claim and consider this SSA decision. Hartford refused to reopen the claim to consider the post appeal denial SSA decision. Hooks sued.
Whether the ERISA Plan must consider SSA determinations issued after a final appeal decision has been rendered?
Should the Court remand back to the claim administrator to consider the post appeal SSA decision?
HOLDING/RATIONALE: New evidence after the appeal decision need not be considered. No remand.
“Review of the plan administrator’s denial of benefits is limited to consideration of the material available to the administrator at the time it is made.” Op. at 2
Remand should be denied because “if the party requesting remand desired new evidence to be in the administrative record it should have acquired that evidence before the appeals process ended.” Op. at 2.
But watch out for this: Remand might have been appropriate if Hooks had alerted Hartford to the pending SSA determination before the appeals process closed. Op. at 2. (Case citation omitted).
Imposing a remand to consider new information obtained after the final appeal decision “would undercut longstanding precedent in ERISA jurisprudence and…would ‘require a reassessment of the entire regime of ERISA litigation.’” Op. at 3.