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ERISA Denial of Benefits Affirmed, Despite Award of SSDI Benefits

ERISA Denial of Benefits Affirmed, Despite Award of SSDI Benefits

Sobh v. Hartford Life and Accident Ins. Co., 2016 WL 3564380 (11th Cir. July 1, 2016)


ERISA and Life Insurance News
(November, 2016)

Sobh, a former employee of JPMorgan Chase Bank, sued to recover long term disability benefits under his employer’s ERISA plan after his claim was denied under the “any occupation” standard. The denial of benefits was based in part on a surveillance video, described as reflecting no impairment, and the opinion of an independent medical examiner that Sobh was capable of employment that allowed for frequent positional changes.

Hartford acknowledged that Sobh had been awarded Social Security disability benefits, but according to the court, the company “explained why Hartford reached a different conclusion than the Social Security Administration regarding disability benefits.”  During the administrative review of the claim denial, Hartford noted that the definition of disability in the plan was different from that utilized by Social Security, and that Hartford had reviewed “key evidence” that was not considered by the Social Security Administration, including the surveillance material and the opinion of the treating physician that Sobh could “perform full-time sedentary work.” 

The trial court granted summary judgment in favor of Hartford, and Sobh appealed. Affirming the trial court’s ruling, the Eleventh Circuit noted that its decision was not altered by the decision of the Social Security Administration.  First, the court wrote, the determination of disability under the plan differed significantly from the “framework” utilized by the Social Security Administration. In a footnote, the court elaborated that “[u]nlike ERISA claim administrators, whose disability assessments are governed by plan documents, the Social Security Administration employs a highly particularized, five-step ‘sequential evaluation process’ prescribed by regulations.” 

Moreover, “the circumstances that caused Hartford to conclude that Sobh was no longer disabled did not occur until two years after the Social Security Administration’s determination.” 

Specifically, the court noted, the “Social Security Administration did not have before it at the time it made its disability determination, the surveillance video recordings or Sobh’s treating physician’s opinion that Sobh was able to perform sedentary work.”  As a result, the earlier Social Security determination was “of little consequence.”

Click here to view the full November 2016 Edition of the ERISA and Life Insurance News.

Authors
H. Sanders Carter
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Andrea K. Cataland
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Kenton J. Coppage
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Mary B. Ramsay
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Jennifer Noland Rathman
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