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Social Security Disability Award Not Determinative of ERISA Disability Claim

Social Security Disability Award Not Determinative of ERISA Disability Claim

ERISA and Life Insurance News
(June 6, 2013)

Hunter, a former director of events for Hilton Hotels, sued Aetna Life Insurance Company to recover long-term disability benefits under his employer’s ERISA plan.

With diagnoses of sarcoidosis, hypertension, and pain in both knees, Hunter received benefits under the two-year “own occupation” test until Aetna received information from his treating physician that Hunter should be able to return to work. Although the physician later changed her opinion somewhat, she nevertheless agreed that Hunter should be able to do sedentary or light duty work.

Based on this opinion, the opinions of three independent reviewers, and the results of a vocational analysis, Aetna maintained its denial of benefits under the “any occupation” standard.

On cross-motions, the court considered whether Aetna had given sufficient consideration to an award of Social Security disability benefits. Aetna had noted the SSDI award in its letter denying Hunter’s appeal, but pointed out that Hunter had not submitted to it the underlying documents demonstrating the basis for the Social Security decision.

The court agreed that “[l]acking more, Aetna could not fairly be required to give greater explanation for how its decision differed from the SSA’s.” The court also noted that the SSA award was made before the treating physician had stated that Hunter could return to work. Thus, the court wrote, “it is possible that Aetna’s conclusion was based upon a more complete medical record than the SSA’s.”

Click here to view the full June 2013 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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