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The Wagner Law Group Description 

The Wagner Law Group, A Professional Corporation, is a nationally recognized ERISA & employee benefits, estate planning, employment, labor & human resources practice. 

 

Established in 1996, The Wagner Law Group has 23 attorneys engaged exclusively in employee benefits, estate planning and employment law. Seven of our attorneys are AV rated by Martindale-Hubbell as having very high to preeminent legal abilities and ethical standards. The firm is among the largest ERISA boutiques in the country. Our practice is national in scope, with clients in more than 40 states and several foreign countries.

 

 

 

 

 

Contact Info

The Wagner Law Group

 

  Integrity | Excellence

  

Massachusetts Office 

Tel: (617) 357-5200 

Fax: (617) 357-5250 

99 Summer Street 

13th Floor

Boston, MA 02110


Florida Office 

Tel: (561) 293-3590
Fax: (561) 293-3591
7108 Fairway Drive
Suite 125
Palm Beach Gardens, FL 33418

   

San Francisco Office

Tel: (415) 625-0002

Fax: (415) 358-8300

315 Montgomery Street

Suite 904

San Francisco, CA 94104

 

www.wagnerlawgroup.com

 

 

 

 

January 23, 2014

 

 State and Federal Law Alert

 

 

 

LTD Insurer Must Consider Evidence Developed During SSDI Application Process 

 

 

 

The United States Court of Appeals for the Eleventh Circuit recently reviewed whether a long-term disability ("LTD") insurer must consider evidence generated as a result of a claimant's application for Social Security Disability Income ("SSDI") benefits. In deciding Melech v. Life Insurance Company of North America, the Eleventh Circuit held that when an LTD policy requires a claimant to apply for SSDI benefits, procedural fairness requires the LTD insurer to consider evidence developed during the SSDI application process.

 

Background

 

In Melech, the plaintiff's orthopedist diagnosed her as having degenerative disc disease and ordered her to stop working. Consequently, she filed a claim for benefits under her employer's LTD plan. The LTD policy required her to file a claim for SSDI benefits through the Social Security Administration ("SSA") because any SSDI benefits would offset the insurer's payments.

 

As required, the plaintiff filed an SSDI application. However, while her SSDI claim was pending, the insurer denied her LTD claim. As part of the SSDI process, SSA required the plaintiff to visit two specialists for independent evaluations. Based on these evaluations, SSA approved her SSDI claim.

 

The plaintiff next filed an appeal with the insurer and informed it of the independent evaluations and the SSA decision to award SSDI benefits. Nevertheless, the insurer upheld its decision to deny the plaintiff's LTD claim, reasoning that SSDI decisions are independent of its LTD determinations. In response, the plaintiff sued, alleging that the insurer violated the terms of the LTD policy and ERISA.

 

The district court upheld the insurer's decision and the plaintiff appealed to the Eleventh Circuit.

 

Eleventh Circuit Ruling

 

In reviewing the case, the Eleventh Circuit clarified that it was not determining the propriety of the insurer's ultimate decision to deny the plaintiff's LTD claim. Instead, the Eleventh Circuit analyzed the relationship between SSDI benefits and LTD benefits under the policy and determined that the insurer was obligated to consider evidence developed during the SSDI application process. The insurer did not have this evidence when it initially denied the plaintiff's LTD claim or when it denied her appeal.

 

The Eleventh Circuit concluded that the insurer's failure to consider the evidence developed during the SSDI application process was procedurally unfair and inconsistent with the "fundamental requirement that an administrator's decision to deny benefits must be based on a complete administrative record." The Eleventh Circuit reasoned that after requiring the plaintiff to seek SSDI benefits as required by the LTD policy, the insurer was not then free to ignore the resulting evidence. It therefore vacated and remanded the district court's decision, with instructions that the case be sent back to the insurer for further administrative consideration in light of the evidence developed during the SSDI application process. 

 

 

 

 

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This Newsletter is provided for information purposes by The Wagner Law Group to clients and others who may be interested in the subject matter, and may not be relied upon as specific legal advice.  This material is not to be construed as legal advice or legal opinions on specific facts. Under the Rules of the Supreme Judicial Court of Massachusetts, this material may be considered advertising.