Are Social Security Administration disability determinations, issued after the final appeal decision, part of the ERISA administrative record? NO.
Plaintiffs often seek reversal of a denial of ERISA-governed disability benefits because the claim administrator failed to conduct an independent medical exam (IME).
But is the failure to conduct an IME fatal to a claim denial? NO. Check to see if the plan language expressly “reserved the right” to an IME.
Here’s the case of Folds v. Liberty Life Assur. Comp., 2016 WL 5661615 (N.D. Ohio September 30, 2016) (attached) that highlights these points, some other nice pearls of thought, too.
FACTS: Folds had “inflammation of the digestive tract” and sought ERISA-governed disability benefits administered by Liberty Life. Liberty provided disability benefits for ten months and then determined Folds was no longer disabled because there was no evidence he could not perform the essential functions of his desk job.
Folds could not stomach this decision and appealed. When multiple appeals were denied he filed suit, claiming Liberty’s decision was arbitrary because: (1) no IME had occurred; (2) Liberty did not give due weight or overlooked Plaintiff’s treating physician’s opinions and vocational assessment; and (3) Liberty’s decision differed from the Social Security (SSA) disability determination.
DISTRICT COURT HELD: Liberty’s decision to discontinue benefits AFFIRMED.
- Plaintiff claimed Liberty should have conducted an independent medical exam before claim denial because the medical record review made “credibility determinations” and in those situations an IME is required. However, the court determined no IME was required here because the “Plan [did not] explicitly reserve the right to mandate a physical examination.” Op. at 17.
- The SSA determination was NOT part of the administrative record and was excluded. Four days after Liberty had denied his appeal, the SSA issued a decision concluding Folds was disabled. “Because the SSA’s notice was issued after [Liberty’s final appeal decision], it was not part of the evidence considered…[and] is not part of the administrative record….” Op. at 13.
- The Court concluded Liberty “need only ‘provide an explanation for resolving conflicts between the treating physician and [Liberty’s] consulting physician.” Op. at 19.
- “’[I]t is entirely reasonable for an insurer to request objective evidence of a claimant’s functional capacity.’” Op. at 27.