What happens when the Social Security Administration issues a disability finding after the ERISA administrator has issued the decision denying disability benefits?

Is the ERISA administrator obligated to reevaluate the record based on this new finding? No.

Should the Court consider this as “evidence” in a subsequent lawsuit?  No.

This new case highlights

You know that the standard of review applied by courts will significantly impact how courts view an ERISA Plan administrator’s interpretation of an undefined plan term.

But what impact should an insurer’s policy manual have in assessing the “intent” of a plan term?  NOT MUCH.

This new case highlights both points.

Caldwell v. Unum

You already know that ERISA regulations set specific timelines for the issuance of ERISA-governed long term disability decisions. See, e.g., 29 C.F.R. 2560.503-1(i)(1)(i) (45 days for disability claims and 60 days for others). In special circumstances, the administrator can extend the time by which benefit decisions are made.

An administrator’s failure to issue benefit

What does it mean to be totally disabled from the “regular occupation”? 

Is “regular occupation” defined as the duties the claimant is actually doing in his or her specific job?  NO.

Each claim should be assessed from the perspective of duties of the job generally in the national economy and not how the job

When does evidence of malingering justify denial of a long term disability claim?  It depends. A physician’s subjective opinion regarding malingering may have less weight than objective neuropsychological testing.

Key Take Away:  When the claimant’s neuropsychological testing is rendered invalid due to “failed validity tests,” that may be enough to deny the claim.

You already know that ERISA sets forth a 180-day time limit for internal administrative appeals of benefit denials.

And failure to pursue a timely internal administrative appeal can subject the claimant (in a later federal lawsuit) to the defense of failure to exhaust administrative remedies.

But can a claimant save an untimely administrative appeal by