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Social Security Award of Disability Benefits Does Not Control ERISA Claim Determination

Social Security Award of Disability Benefits Does Not Control ERISA Claim Determination

ERISA and Life Insurance News
(August 21, 2012)

Hepworth, a registered nurse, sued to recover ERISA disability benefits after the insurer terminated her ongoing claim, concluding that the medical evidence did not support total disability from “any occupation.” LINA counterclaimed to recover an overpayment resulting from Hepworth’s receipt of Social Security disability benefits.

Hepworth contended that she was totally disabled as the result of injuries to her neck, back, and left shoulder. While at least one of Hepworth’s physicians supported her claim, others completed forms indicating that she retained functional ability that was not inconsistent with sedentary work. A consulting physician reviewed the medical evidence and concluded that the record lacked “documented significant quantified findings” that would support a disability claim.

Hepworth argued that the plan did not require “clinical exam findings” and that it did “not differentiate between objective and subjective findings.” The court, however, noted that the plan required proof of continued disability and the submission of “satisfactory proof of Disability” in order to obtain benefits.

Hepworth also argued that LINA failed to consider her favorable Social Security decision. The court noted the “general rule” that such decisions are “not considered dispositive on the issue of whether a claimant satisfies the requirement for disability under the ERISA-covered plan.”

The Administrative Law Judge in the Social Security proceedings had determined that Hepworth was “unable to sustain an eight-hour work day because of her pain and the effects of her pain medication.” Specifically, the ALJ had concluded that Hepworth was “markedly limited in her ability to maintain concentration, persistence and pace.”

The district court found nothing in the record before LINA that supported impairment from working as the result of such issues. Indeed, a functional capacity evaluation submitted by Hepworth indicated that, at a minimum, she had the ability to perform sedentary work for a 40-hour week.

The trial court granted summary judgment to LINA, concluding that the company’s decision to terminate benefits was not de novo “wrong.” The court also upheld LINA’s right to recover the overpayment and directed the parties to submit evidence concerning the amount of the overpayment.

Click here to view the full August 2012 Edition of the ERISA and Life Insurance News.

H. Sanders Carter
T (404) 962-1015
F (404) 962-1220
Kenton J. Coppage
T (404) 962-1065
F (404) 962-1256
Dorothy H. Cornwell
T (404) 962-1096
F (404) 962-1246

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