The 9th Circuit of Appeals (the federal appeals circuit which covers California) has determined that a long term disability insurer abused its discretion when it failed to consider two things:
- A Social Security Disability Insurance (SSDI) award
- Subjective complaints by the disabled worker.
Social Security Disability Insurance Awards Must Be Considered
If you receive SSDI, the determination by the Social Security Administration (SSA) that you are disabled, is not binding on the insurer. However, they must consider, and “grapple” with it. In the 9th Circuit, LTD insurers must meaningfully review any Social Security Administration conclusions. And if they end up disagreeing with the SSA’s finding of disability, they must give their reasons for doing so.
Not distinguishing the SSA’s finding of disability, is evidence that the meaningful review did not take place.
So if you receive SSI or SSDI, that means the SSA determined you are disabled. If your long term disability insurance company (whether covered by ERISA or not) then denies your application for disability benefits, they must state why they came to a different conclusion than the SSA.
Subjective Complaints By The Disabled Worker Must Be Considered In LTD Cases
The worker in this case suffered from Chronic Pain Syndrome. Chronic pain syndrome is one of those medical conditions that cannot be verified by objective testing (such as X-Rays, MRIs, or other imaging) and must rely on subjective complaints by the sufferer.
In cases where the medical condition cannot be verified by objective medical evidence, the insurance company cannot deny the claim based on lack of objective medical evidence. In this case, the “Independent Medical Examiner” (who isn’t really independent as they are hired by the insurance company) observed the claimant exhibiting pain symptoms during his medical exam. The doctor also noted the long history of chronic pain.
Many medical conditions depend for their diagnosis on patient reports of pain or other symptoms, and some cannot be objectively established,” but “a disability insurer [cannot] condition coverage on proof by objective indicators … where the condition is recognized yet no such proof is possible.” Id. Pain is an inherently subjective condition, and it is unclear what objective evidence the Plan was looking for in order to establish that Cruz-Baca’s pain prevented her from working. Neither the Plan nor Dr. Srinivasan offered any explanation as to why Cruz-Baca’s history of pain and pain-related treatment were insufficient to support a finding of disability. Under such circumstances, to disregard Cruz-Baca’s subjective complaints of continuing and pervasive pain was arbitrary and capricious.
The court also found this as an abuse of discretion by the Edison International Long Term Disability Plan, an ERISA plan.
While I did not handle this case, and this is just a summary of a disability case, if Edison or any other company denied or terminated your benefits, call us right now at (858) 999-2870, or Toll-Free at (888) 320-2058. Or just fill out our contact form on this page and we will respond promptly.Failure to Review SSDI Abuse of Discretion in ERISA LTD Case