ERISA – 11th Cir. — Social Security Determinations Issued AFTER Initial Claim Denial Must Be Considered?

You already know that a Social Security disability (SSDI) decision should be considered in the context of deciding whether the claimant is disabled under the terms of the disability policy.

But what happens when the SSDI decision occurs after you denied the claim, but during the ERISA-governed administrative appeal?

BETTER YET: What happens when the claimant refuses to send you the SSDI determination during the appeal process?

Read this new decision.  It seems to lower the claimant’s burden of proving entitlement to disability benefits, and creates more burdens for claim administrators.

Here is the case of Melech v Life Insurance Company of North America, 739 F.3d 663 (11th Cir. 2014)(“LINA had an obligation to consider the evidence presented to the SSA [even though LINA asked the claimant to submit additional information during appeal and claimant refused and] LINA did not have this evidence when it denied her last appeal—and in fact could not have had that evidence when it initially denied her claim….”)

FACTS:  Melech, a Hertz station manager, experienced back problems and sought disability benefits under the Hertz ERISA-governed plan, administered by LINA. She concurrently applied for Social Security disability benefits (SSDI). In November 2007 the plan denied her disability claim. Melech’s application for SSDI benefits was still pending at the time of denial.  Melech timely filed two administrative appeals.

During the administrative appeals, Melech informed LINA that the Social Security Administration (SSA) had Melech examined by two new physicians, and had granted her SSDI benefits in February 2008.  LINA denied her first in appeal in April 2008. LINA invited Melech to submit additional evidence in a second appeal. Melech refused to submit any SSDI information.  LINA then denied the second appeal in October 2008, without considering the SSA decision.

ISSUES:

Whether an SSA disability determination, issued after initial claim denial, must be considered during an appeal?

Whether the claimant has a duty to send the claim administrator SSDI information?

DISTRICT COURT: LINA’s decision is affirmed.  Review was limited to the administrative record before LINA at the time of its final decision. The SSDI determination was not part of the administrative record and the District Court did not consider it.

11th CIRCUIT:  REVERSES and REMANDS

RATIONALE:

  1. LINA had an obligation to consider the evidence presented to the SSA [even though LINA asked the claimant to submit additional information during the appeal and claimant refused and] LINA did not have this evidence when it denied her last appeal—and in fact could not have had that evidence when it initially denied her claim….”  Op. at 3.
  2. “LINA made general requests for more evidence, but never asked Melech or SSA—as it was authorized to do by the disclosure authorization form—for any documentation of her SSDI award or any of the evidence that the SSA considered in approving her application.”  Op. at 16.
  3. “We conclude that LINA should have considered the evidence generated by the SSA process….” Op. at 17.
  4. “LINA refused to wait for the SSA evidence….”  Op. at 24.

Topics:  Denial of Benefits, ERISA, Social Security, Social Security Disability

Published In: Civil Procedure Updates, Labor & Employment Updates

DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

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