Disability carriers often deny long term disability (LTD) benefits after glossing over, or completely ignoring, the fact that the federal Social Security Administration (SSA) found you to be disabled. It is imperative to include in the appeal of the carrier’s denial of LTD benefits, your medical evidence upon which the SSA relied, the SSA’s reasoning, analysis, and the legal standard upon which the SSA found you to be disabled.
The court may permit the introduction of additional evidence necessary to enable it to make an informed and independent judgment. The court may not consider the record fully developed without inclusion of the social security determination as such evidence is necessary for an informed judgement.
A court may find that you have met the carrier’s requirements for LTD benefits because your treating doctors have found you disabled in physical, cognitive or visual areas. The court may also find it significant that none of your treating physicians have ever released you to work. Moreover, if the insurance company is relying on its own doctor even though he never examined you, then the personal examinations, diagnosis, and treatment by your own doctors should trump the carrier’s doctor.
Courts have held that it is likely more difficult for a claimant to prove that she is disabled from any occupation (the social security standard) than to prove that she is disabled from her regular occupation (carrier’s standard). Accordingly, the social security determination could corroborate the conclusion that you are disabled from performing your regular occupation.
A grant of social security benefits to you has additional significance. There exists case law that your LTD carrier who “prevailed” before the SSA in a practical sense because the grant of social security benefits to you, reduced the amount of your claim against the LTD policy. To lighten the cost to the LTD benefit plan, your carrier likely encouraged and supported your effort to demonstrate total disability to the SSA. To further lighten that cost, your carrier then turned around and denied that you are totally disabled. “In effect, having won once the defendants repudiated the basis for their first victory in order to win a second victory. This sequence casts additional doubt on the adequacy of their evaluation of [the claimant’s] claim, even if it does not provide an independent basis for rejecting that evaluation”, opined one court on the matter.
The key to a successful appeal is to prevent your carrier from winning twice by terminating your benefits in direct conflict with the SSA determination.
Alan C. Olson practices employment law in New Berlin, Wisconsin. AOlson@Employee-Advocates.com
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