The federal district court in Maryland upheld the termination of disability benefits despite the claimant's award of Social Security disability benefits, explaining that "what qualifies as a disability for social security disability purposes does not necessarily qualify as a disability for purposes of an ERISA benefit plan [because] the benefits provided depend entirely on the language in the plan."
Martin was a former graphic designer whose job required him to work on a computer most of the day, read extensively, walk short distances, lift up to 20 pounds, and commute by car 18 miles to and from work. He participated in his employer's group benefit plan that defined disability to mean "you are prevented from performing one or more of the Essential Duties of Your Occupation."
Martin alleged that he became disabled as the result of Meniere's disease, which he claimed resulted in vertigo, dizziness, loss of balance, and tremors of the hands and head, which made him unable to drive or use the computer for long periods of time. He stopped working in April 2009.
Martin saw several medical professionals for his illness, including a nurse practitioner who made the diagnosis of Meniere's disease. However, the record was unclear whether his treating physicians independently verified the diagnosis or merely adopted the nurse practitioner's diagnosis. One treating physician wrote that Martin's "history [was] not strongly suggestive of Meniere's disease." Another diagnosed diffuse arthralgia, and a third treating physician diagnosed benign essential tremors and titubation.
One of the doctors noted that Martin "is disabled far out of proportion to his symptoms and physical examination and underlying psychiatric illness including anxiety and depression is considered the differential diagnosis." Martin was also given a doctor's note stating that he might not be able to pass a sobriety test.
After contacting the nurse practitioner, who reported that Martin was "currently unable to work," because he could only "use a computer for 15-30 [minutes] and read up to 20 [minutes] without triggering an episode," that "[h]is episodes also increase in rainy weather," and that he was "only able to drive 2–3 miles," Hartford began paying long-term disability benefits in October 2009. In September 2010, Martin was awarded Social Security disability benefits, following examinations by two physicians working for the Social Security Administration.
In February 2010, Hartford learned that Martin's self-reported daily activities included watching television, checking his email, working in his yard, and playing guitar. Because Hartford believed that these activities were inconsistent with the reported limitations — the inability to look at a computer screen and hand tremors —it investigated the claim.
In March 2010, an investigator video recorded Martin working on his cars and seeding his front lawn. In the surveillance videos, Martin was seen bending, reaching, squatting, rising, and walking normally without signs of dizziness or imbalance for several minutes at different times of day. Hartford concluded that the video footage also conflicted with Martin's self-reported symptoms, and an investigator was sent to interview him at home.
After the interview, Hartford hired an otolaryngologist and independent consultant to review Martin's medical records and the surveillance videos. The consultant contacted one of the treating physicians, who reported that "in general, he does not regard patients with conditions like this as being permanently and continuously impaired — symptoms may be intermittent, and between episodes they may be able to function normally."
After his review, the independent consultant concluded that Martin could handle "a full-time light physical demand level up to 40 hours per week," which was consistent with that required by his job as a graphic designer, classified as a "sedentary occupation" with light physical demands. In November 2010, after the independent review, Hartford terminated the payment of disability benefits.
When Martin appealed, Hartford hired specialists in otolaryngology and internal medicine to review his file, and ultimately upheld the termination of benefits.
In ruling on the parties' cross-motions for summary judgment, the court applied the abuse of discretion standard, because the plan vested the plan administrator with discretionary authority to make eligibility determinations. Martin argued, among other things, that Hartford had abused its discretion in terminating benefits because he had been awarded Social Security disability benefits. In response, Hartford asserted that the standard governing the award of Social Security disability benefits differed from those of the plan, reiterated that substantial evidence supported its decision, including independent reviews by two additional physicians, and asserted that the mere presence of some ailments does not automatically compel a finding of disability.
In addressing the difference between the standards under an ERISA plan and the standards under the Social Security Act, the court wrote:
Unlike the Social Security program, ERISA does not "require employers to establish employee benefit plans" or require that employers provide a particular set of benefits. Black & Decker, 538 U.S. at 833. "Accordingly, what qualifies as a disability for social security disability purposes does not necessarily qualify as a disability for purposes of an ERISA benefit plan-the benefits provided depend entirely on the language in the plan." Smith v. Cont'l Cas. Co., 369 F.3d 412, 420 (4th Cir. 2004). When considering whether a beneficiary receiving Social Security disability benefits is also entitled to benefits under the Plan, "there is no obligation to weigh the agency's disability determination more favorably than other evidence." Gallagher v. Reliance Standard Life Ins. Co., 305 F.3d 264, 275 (4th Cir. 2002) (internal quotation marks and citations omitted). Thus, "the mere grant of benefits by an agency that applies a different standard or a different definition of disability does not render [denial] of benefits under the Plan unreasonable." Simmons v. Prudential Ins. Co. of Am., 564 F. Supp. 2d 515, 524 (E.D.N.C. 2008).
Thus, the court concluded that in relying on the opinions of its consultants, particularly in the face of conflicting evidence of disability, Hartford did not abuse its discretion. The court noted that Hartford had not ignored the award of Social Security benefits, but rather, had accounted for all the evidence, as it was required to under the abuse of discretion standard. As a result, the court granted summary judgment, upholding Hartford's claim decision.
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