Disability Benefits


These executive summaries were compiled from EMPLOYEE BENEFITS INFOSOURCE database, a source for information on employee benefits and human resources.

DOL Proposes More Stringent Rules for Disability Claims Procedures.
Laderman, Leslye; Harrison, Mary; Buck Consultants: FYI; v38 no13 pp 1-5 Dec 2015; journal article

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Abstract : Prompted by rising litigation over disability benefits, the DOL proposed regulations to strengthen the benefits adjudication process, mirroring the Affordable Care Act's rules for handling claims appeals in nongrandfathered ERISA group health plans. The November 2015 proposal applies to adverse disability benefit decisions including rescission. Plans would have to explain adverse decisions initially and after an appeal is denied, sharing the basis for disagreement with the treating physician or other care provider, information about criteria used by the plan and a statement of the claimant's right to relevant documents in culturally and linguistically appropriate formats. The claims procedure must support a full and fair review, permit the claimant to review his or her file, present additional evidence and have an opportunity to respond to added evidence. The rules also explain that if a plan violates the process, the claimant is seen to have exhausted administrative remedies and proceed with litigation.

DMEC: Customizing Integrated Disability Management Improves Outcomes.
Thompson's ADA Compliance Guide; v26 no12 pp 4-5 Dec 2015; journal article

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Abstract : Integrated disability management (IDM) is an approach to managing absences, from occupational or other causes, by coordinating disability, workers compensation and absence programs. Cases and claims are tracked together and return to work is encouraged, not just by offering light duty, but by bringing together the services of human resources, risk management and other departments. The goal is a transitional work assignment that is medically appropriate and helps the employee resume full productivity. Benefits come from group health insurance, disease and disability management, wellness plans and personal coaching and on-site workplace intervention. One in five companies attending a Disability Management Employer Coalition (DMEC) webinar incorporates all elements in their IDM program. Raytheon and Textron Aviation discussed their successes using a centralized process for requesting and tracking requests for leave, which helps streamline notifications and metrics. Both stressed the importance of tailoring an IDM program around the needs of the organization and its employees.

Maternity or Parenting Leave: A Difference with Several Distinctions.
Bischoff, Kate; Family and Medical Leave Handbook; v23 no9 pp 1, 9-10 Dec 2015; journal article

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Abstract : Many employers offer paid or unpaid parental leave to employees as an extra perk or fringe benefit of employment. However, employers must be cautious about how the parental leave policy is worded in order to avoid gender-based discrimination and potential lawsuits. Maternity leave is often granted due to a temporary disability and that leave can be taken using short- or long-term disability or can be drawn from the existing pool of paid time off. Fathers are not granted this type of leave, but they are afforded leave to bond with or take care of their child, whether it is a biological or adoptive child. In order to avoid discrimination, employers could offer maternity disability leave separate from parental leave that is offered to both male and female employees. This concept came about from the Johnson v. University of Iowa case, where a father was denied the use of his paid time off even though that right was afforded to female employees at the university. The court found against Johnson because the leave females were given was tied to short-term disabilities stemming from childbirth.

Requiring Employee to Return 'Fully Healed' Is Playing With Fire.
Nowak, Jeff; Thompson's ADA Compliance Guide; v26 no12 pp 1, 8 Dec 2015; journal article

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Abstract : Company policy requiring an employee on disability to be fully healed before returning to work is risky, leaving the employer vulnerable to discrimination charges. When Brookdale Senior Living Communities enforced such a policy and ultimately terminated an employee seeking accommodations for fibromyalgia, the Equal Employment Opportunity Commission charged the employer with failure to accommodate under the Americans with Disabilities Act (ADA). The case was settled with the employer paying back pay and damages and mandated to provide ADA training and report on any discrimination complaints. Most courts have ruled the fully healed policy to be discriminatory against the disabled, disregarding ADA rules for individual assessment and accommodations. Employers should ask returning employees for permitted medical information and a fitness-for-duty certificate indicating their ability to perform essential job functions with or without accommodation.

Treatment of Subjective Plan Complaints in ERISA Disability Claims.
Salkin, Barry L.; Benefits Law Journal; v28 no4 pp 40-54 Winter 2015; journal article

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Abstract : Several conditions including persistent headache, chronic fatigue syndrome and fibromyalgia are challenging for ERISA plan administrators and insurers, leading to multiple legal cases over disability. Symptoms for these conditions are subjective, and there is no known cause or cure. The Fourth Circuit Appeals Court stressed the need to consider both objective and subjective evidence of disability, though administrators may weigh the two differently. Administrators' requests for objective evidence must be reasonable. Various methods may be used to assess the plaintiff's credibility. While some plans' language limit benefits to 24 months for health limitations based on self-reported symptoms, the Seventh Circuit ruled in Weitzenkamp v. Unum Life Ins. Co. of America that the focus of scrutiny should be self reporting for diagnosis, not for functional limits, and that the 18-point trigger test provided sufficient verification for a fibromyalgia diagnosis.

Insurer Properly Denied Benefits for Failure to Meet "Actively at Work" Requirement.
Benefits Magazine; v52 no11 p 63 Nov 2015; journal article

Availability : International Foundation of Employee Benefit Plans
Abstract : The U.S. District Court for the District of Colorado granted the defendants a summary judgment in the Shafer v. Metropolitan Life Insurance Company et al. case. The plaintiff was the wife of a deceased employee, and the defendant was a life insurance provider. The plaintiff received a life insurance payoff after her husband died, but it was not the amount for the plan the plaintiff believed the husband had enrolled in. The husband's being on disability and not actively at work when his benefits began made him ineligible for the plan with enhanced benefits. The plaintiff claimed the defendants denied the claim without providing her husband with information stating he had to return to work to get the full benefits. The court found the company the plaintiff's husband worked for was responsible for providing that information, not the life insurance company.

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Long-Term Disability Case Remanded for Insufficient Review.
Benefits Magazine; v52 no11 pp 65-66 Nov 2015; journal article

Availability : International Foundation of Employee Benefit Plans
Abstract : Diagnosed with degenerative disc disease, the plaintiff in Mead v. ReliaStar Life Insurance Company sought but was denied long-term disability (LTD) benefits for inability to perform her own occupation. The defendant relied on an independent medical consultant, while the plaintiff, in her appeal, presented multiple evaluations and documentation to no avail. In 2005 the District Court for Vermont remanded the case for further review, which carried on for four years before the court granted the plaintiff 24 months of benefits related to her own occupation. The defendant calculated benefits on salary and wages, excluding other compensation, and denied benefits for any occupation, but did not explain physical requirements of any other occupation, offer reasonable accommodations or respond to other evaluations. The court granted the defendant's motion regarding benefits calculation but remanded the case to the administrator to evaluate the plaintiff's ability to work at any occupation for which she is qualified.

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Disability Benefits Denial Affirmed.
Benefits Magazine; v52 no10 p 55 Oct 2015; journal article

Availability : International Foundation of Employee Benefit Plans
Abstract : The Second Circuit Appeals Court ruled a multiemployer pension fund's denial of benefits was not arbitrary and capricious but showed proper discretion within the limits of the plan. The plaintiff in Ocampo v. Building Service 32B-J Pension Fund et al. worked as an office cleaner in covered employment under the plan until 2005. Due to herniated discs in her back, she stopped work, filed for and was awarded disability benefits through the Social Security Administration (SSA), with the award to be reviewed at least every three years. In 2011 she applied for disability benefits through the defendant plan but was denied, first for incomplete documentation showing her disability was permanent and later due to the SSA's three-year reevaluation requirement. The plan required an application within nine months after the end of work for a disability to be considered total and permanent. The Appeals Court upheld the district court in finding the defendant had discretion to make benefit determinations and followed the clear terms of the plan.

Employer Coordination of Regulatory Laws for Dissemination of Information and Cost Control.
Ronca, Theodore J.; Employee Benefit Plan Review; v70 no4 pp 16-18 Oct 2015; journal article

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Abstract : Too often the lack of coordination and a focus for communications in various claims situations result in frustration, higher costs and lost time. Employers are bound by numerous state and federal laws in response to claims. An employer program for coordinating claim efforts should start with an inventory of all applicable laws, analysis of how they may interact and method for obtaining permissions for disclosures from a claimant. The core of the program is expanding the employer's ability to communicate with the employee, and coordinating regulatory program responses can streamline overall compliance. Every employer's program will be unique and can extend from handling work-related injuries to coordinating retirement and disability claims, absenteeism and discharge for cause.

Extended Deadline Permitted for Disability Benefits Appeal.
Benefits Magazine; v52 no10 p 58 Oct 2015; journal article

Availability : International Foundation of Employee Benefit Plans
Abstract : The Ninth Circuit Appeals Court reversed the lower court in LeGras v. Aetna Life Insurance Company et al., a case about the limits of the appeals period after a benefits denial. The defendant notified the plaintiff that disability benefits for a back injury would end on a certain date unless the disability qualified as a total disability. The 180-day appeals period ended on a Saturday, and the plaintiff sent his appeal the following Monday. The defendants denied the appeal, stating the plaintiff failed to exhaust administrative remedies due to the late appeal. With no specific ERISA or DOL guidance, the Circuit Court cited DOL Regulation 29 C.F.R. 2560.503-1(h) allowing at least 180 days and Federal Rule of Civil Procedure 6 extending a deadline falling on a weekend or legal holiday to the end of the next day. The court remanded the case for the defendant insurer's further consideration.

Putting It All Together: Benefits Integration Boosts Health, Productivity.
English, Karen Trumbull; Benefits Magazine; v52 no10 pp 32-37 Oct 2015; journal article

Availability : International Foundation of Employee Benefit Plans
Abstract : A comprehensive approach to employee health care integrates disability and absence programs. Integrated disability management covers medical leave, workers compensation and often return-to-work programs, while total absence management adds any other absence. Health and productivity management adds behavioral health, wellness and population management. Integrating benefits improves tracking, reporting, administration and regulatory compliance, while lowering costs and improving productivity. Organizations moving to integrated benefits management should formalize a philosophy, set a long-term strategy and make a business case. They should analyze plans for links and incentives and have an overall technology platform to track and report on absences. The process may be phased or implemented all at once, and it may be managed in house or outsourced.

Social Security and LTD Awards.
Salkin, Barry L.; Benefits Law Journal; v28 no3 pp 60-71 Autumn 2015; journal article

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Abstract : A claimant may qualify for disability benefits from the Social Security Administration but still be denied benefits through private long-term disability (LTD) insurance on the basis of the same administrative record. Though the plan administrator should consider the Social Security award, the agency's decision is not binding on the ERISA plan administrator. Several differences may lead to different conclusions, including definitions of disability, divergent evidentiary and procedural rules, different or more recent information available and even error in the Social Security decision. Cited cases show the importance of the plan administrator's addressing contrary Social Security Administration awards, explaining how such differences produced distinct results and explicating any potential conflict of interest that could influence procedural fairness.

The ADA at 25: Where We've Been, Where We Are and Where We're Going.
Hyman, Jonathan T.; Leave and Disability Coordination Handbook; v19 no1 pp 2, 10-11 Sept 2015; journal article

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Abstract : The Americans with Disabilities Act (ADA) was enacted July 26, 1990 and was created to ban discrimination of individuals with disabilities in areas of employment, public services, transport and telecommunication. However, some important cases in 1999 such as Sutton v. United Airlines, Murphy v. United Parcel Service and Albertson's, Inc. v. Kirkingburg held that an employee's disability did not fit the ADA if it could be corrected with things such as prescription medications or eyeglasses. In Toyota Motor Mfg., Kentucky, Inc. v. Williams it was decided that to be considered disabled, one must have trouble carrying out tasks of daily living, not just tasks related to employment. In 2009 President George H.W. Bush worked to redefine disability and undo barriers these cases created. The ADA now focuses solely on defending people with disability and making sure they have all the reasonable accommodations the ADA Amendments Act requires, through an interactive process between the employer and employee. The growing list of applicable disabilities includes cancer, asthma, diabetes and major depression.

Disability Plan's Limitations for Mental Disorders Upheld.
Benefits Magazine; v52 no8 pp 57, 66 Aug 2015; journal article

Availability : International Foundation of Employee Benefit Plans
Abstract : An employee filed for long-term disability benefits due to multiple symptoms diagnosed as Lyme disease under one set of criteria but not by the Centers for Disease Control standards. His psychiatrist diagnosed him with major depressive disorder and other psychological conditions. He was granted 24 months of benefits in accordance with plan terms when mental disabilities are involved. On internal appeal seeking an extension, employee insisted his limitations resulted from Lyme disease, but the employer's independent expert determined any disability was not physical. In Dutkewych v. Standard Insurance Company et al. the defendant insurer stressed the plan's mental disorder limitation, when psychological conditions contribute to any disability. The court found the insurer did not abuse discretion, and the First Circuit Appeals Court upheld, finding the insurer's decision based on the plan limitation not to be arbitrary or capricious.

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Other Recent Decisions.
Benefits Magazine; v52 no8 pp 69-70 Aug 2015; journal article

Availability : International Foundation of Employee Benefit Plans
Abstract : In McDonough v. Aetna Life Insurance Company et al. the First Circuit Appeals Court vacated the lower court's summary judgment for the defendant. After suffering strokelike symptoms, the plaintiff was granted long-term disability benefits but was determined to be no longer disabled a year later, based on his physician's opinion that he could perform sedentary work. The appeals court found the decision to end benefits failed to consider the requirements of the plaintiff's job. In Medford v. Prudential Insurance Company of America et al. the District Court for the Eastern District of Pennsylvania granted summary judgment for the plaintiff. The plaintiff elected life insurance coverage for himself and his wife. The wife died while the plaintiff was on short-term disability leave, but the defendant insurer denied benefits, claiming the plaintiff was not actively at work. The court found the plan document ambiguous and the plan administrator's decision to be arbitrary, capricious and an abuse of discretion. In Leon-Serrano et al. v. Northwestern Selecta, Inc. the plaintiff employee and welfare plan beneficiaries asserted the defendant employer failed to provide adequate notification about the availability of COBRA. Though the defendant sent notices to the plaintiff employee's beneficiaries, the recipients challenged the timing and adequacy of the notice, partly because it failed to state each qualified beneficiary had an independent right to elect COBRA coverage or explain ramifications of declining. The court granted summary judgment for the plaintiffs.

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Understanding the Social Security Family Maximum.
Romig, Kathleen; Shoffner, Dave; Social Security Bulletin; v75 no3 pp 1-13 Aug 2015; journal article

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Abstract : Rules for calculating the family maximum benefits for survivors, spouses and children of Social Security recipients are complex and have changed over time. Beneficiaries may be entitled to benefits of different types and from several earnings records, and benefits vary for disability and by earnings level. Beneficiaries for Disability Insurance face tighter rules for the family maximum than Old-Age and Survivors Insurance beneficiaries. For beneficiary families receiving retirement and survivor benefits family maximum rules apply only if three or more family members receive benefits, and auxiliary beneficiaries receive reduced benefits. Reductions imposed by the family maximum can be significant, about 33 percent for families of disabled workers, 23 percent for survivor families and 14 percent for families of retired workers.

How Long Do You Have to Keep an Employee's Job Open for Him or Her?
Panaro, Gerard P.; HR Advisor: Legal & Practical Guidance; v21 no4 pp 51-57 Jul-Aug 2015; journal article

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Abstract : Employers are often required under the Family and Medical Leave Act (FMLA), Americans with Disabilities Act (ADA), state laws, worker compensation laws and even their own policies to hold an employee's position during an excused absence, but not without limits. FMLA leave is up to 12 weeks in most cases or 26 weeks to care for a covered servicemember. The ADA's interactive process to find a reasonable accommodation may extend for months with no clear end point. A request for indefinite leave may not be reasonable, but an employer must be consistent in treatments of requests, past accommodations and explanations and should have a reasonable expectation that the employee will return to work. Terminating an employee who has exhausted all medical leave can backfire if the condition qualifies for ADA protection. Several legal cases illustrate the fine points of timing and accommodations.

Other Recent Decisions.
Benefits Magazine; v52 no7 pp 67-69 Jul 2015; journal article

Availability : International Foundation of Employee Benefit Plans
Abstract : In Perez v. Harris et al. the Secretary of the DOL, as plaintiff, alleged the defendant company's chief executive officer (CEO) failed to remit health plan payments to the insurance company. After a magistrate judge recommended denying summary judgment for the plaintiff, the plaintiff complained the definition of fiduciary was misstated in that judge's report. Finding the key question to be whether the CEO actually exercised fiduciary authority, the District Court for Minnesota accepted the magistrate judge's report despite the misstatement. In Silvaggio v. Cement Masons Local 526 Pension Fund the District Court for Western Pennsylvania ruled against the plaintiff, the wife of a deceased plan participant, who alleged breach of fiduciary duty for the plan's failure to reconfirm the participant's pension benefit election before he died. The election of a 50 percent joint and survivor option yielded higher benefits during his 20-year retirement but dropped to 50 percent for the spouse upon the participant's death. Plan documents specified that the 50 percent option was the default without a valid election. In Corrigan v. Local 6, Bakery, Confectionary and Tobacco Workers et al. the plaintiff contended he never received a COBRA notice that the plan administrator mailed to his last known address. The District Court for Eastern Pennsylvania noted the administrator's good faith compliance with COBRA notice requirements, which stop short of assuring receipt of notice. In Spence v. Union Security Insurance Company, the plaintiff was denied disability benefits initially and on appeal. Though the defendant's final denial stated the case was closed, the plaintiff sued for unpaid benefits nearly a year later. The defendant responded that the complaint was well past the plan's limitations period. The District Court for Oregon ruled that, since the defendant's determination letter failed to inform the plaintiff of his right to bring civil action after a denial, the limitations period was never triggered. In Montoya v. Reliance Standard Life Insurance Company et al. the plaintiff sought full access to reports of independent medical examinations arranged by the defendant insurer for the plaintiff's disability benefits claim. The District Court for the Northern District of California cited the DOL's regulation that documents used for an initial benefit determination must be shared, but those generated through appeal do not need to be shared until after the appeal decision is made.

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Recovery of Benefits Under Section 502(a)(3) of ERISA Denied.
Benefits Magazine; v52 no7 pp 58-59 Jul 2015; journal article

Availability : International Foundation of Employee Benefit Plans
Abstract : In Rochow et al. v. Life Insurance Company of North America the plaintiff estate representatives sought recovery from the defendant insurer that denied disability benefits to a plan participant. The participant suffered symptoms in 2001, was demoted and terminated for nonperformance in 2002, promptly diagnosed with a brain infection and filed for long-term disability benefits. The claim was denied since the participant was not employed when the disability started. The participant filed suit to recover benefits under ERISA Section 502(a)(1)(B) and address an alleged breach of fiduciary duty under Section 404(a). The district court and Sixth Circuit Appeals Court ruled for the participant in 2004. After the participant's death in 2008, the plaintiffs won an additional $2.8 million for profits the defendant earned on benefits not paid to the participant, with the award upheld on appeal as appropriate equitable relief under Section 502(a)(3). In 2014 the defendant sought rehearing on the plaintiffs' entitlement to recovery through both Sections 502(a)(1)(B) for wrongful denial and 502(a)(3) for equitable relief. The Sixth Circuit found the equitable relief award inappropriate since other means of redress were available. The denial of benefits was already remedied through Section 502(a)(1). The court vacated the unjust enrichment award and remanded the case for consideration of prejudgment interest.

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Short-Term Disability Plan Was a Payroll Practice Not Subject to ERISA.
Benefits Magazine; v52 no7 p 62 Jul 2015; journal article

Availability : International Foundation of Employee Benefit Plans
Abstract : In Schra v. Metropolitan Life Insurance Company the plaintiff employee applied for and was granted short-term disability (STD) benefits with two extension periods before the defendant insurer informed her that her benefits claim would be withdrawn. The plaintiff asserted she was told STD benefits still active on a certain date would roll into long-term disability (LTD) benefits automatically. The withdrawal of STD benefits came one month prior to that date. The plaintiff appealed unsuccessfully and sued, alleging abuse of discretion. The defendant argued the plaintiff had never filed for LTD benefits. The plaintiff requested to refile her suit, changing the suit for LTD benefits to seek renewal of her short-term benefits under ERISA Section 502(a)(1)(B). The defendant stated the STD plan was not an ERISA plan but a payroll practice plan, to which the court agreed, leaving no justification for the plaintiff to amend her complaint. The plaintiff argued a long term benefits application would have been futile, but the court noted she did not raise that argument at the appropriate time.

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Disability Tab Shifting to Workers.
Pallarito, Karen; Business Insurance; v49 no13 pp 17-18 suppl. Summer 2015; journal article

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Abstract : Under half of private employers offer disability insurance for their employees, with little change from about 2000 through 2015, but more firms are requiring employees to share the cost. In 2012 LIMRA International Inc. reported that 43 percent of employers offered short-term disability, but only 35 percent paid the full premium, and disability coverage, especially short term, was a voluntary benefit for 23 percent of employees. Some employers reduce coverage to just half of an employee's salary. Hybrid products enabling employers to customize the benefit are emerging, with the option for employees to pay for extra coverage. With these shifts, the need for education on the importance of financial protection during times of disability grows stronger, as do benefits to help employees return to work sooner.

Insurer Did Not Abuse Discretion in Denying Long-Term Benefits.
Benefits Magazine; v52 no5 p 55 May 2015; journal article

Availability : International Foundation of Employee Benefit Plans
Abstract : The Fifth Circuit Appeals Court upheld the lower court's grant of summary judgment for the defendant in Killen v. Reliance Standard Life Insurance Company. The defendant did not extend the two years of disability benefits for the plaintiff's rotator cuff injury because she did not meet the definition of totally disabled, being unable to perform any job for which she was qualified. The plaintiff's primary physician said she was incapable of holding down a job, but her orthopedist and a rehabilitation specialist found her able to perform sedentary work. The district court found no abuse of the plan administrator's discretion in denying the claim, and the Appeals Court concurred, finding the defendant attended to the abundant evidence, provided full and fair review and had no significant conflict of interest in its decision.

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Plan Participant Ineligible for Increased Disability Benefits.
Benefits Magazine; v52 no5 pp 57-58 May 2015; journal article

Availability : International Foundation of Employee Benefit Plans
Abstract : The Eighth Circuit Court of Appeals upheld a lower court's finding that a disability plan administrator correctly followed plan terms in denying benefits for a plan participant. The plaintiff in Brake v. The Hutchinson Technology Incorporated Group Disability Income Insurance Plan bought disability insurance in 1988 and was diagnosed with multiple sclerosis in 2000. When the plan changed insurers in 2005, she opted for extra coverage for her preexisting condition, but the buy up blocked coverage for a disability treated within the prior 12 months. The plaintiff filed for disability benefits in 2008 but was granted only core benefits since she had been treated within the previous 12 months. The courts rejected plaintiff assertions about South Dakota and Minnesota state statutes, noted the buy up option did not change the insurer or replace the previous policy and ultimately affirmed the defendant's interpretation of the policy.

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So Your Employee Has TRD...
Sullivan, Mike; von Heymann, Chris; Benefits Canada; v39 no5 pp 51-53 May 2015; journal article

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Abstract : Treatment resistant depression (TRD) is a major depressive disorder that does not respond well to two or more courses of antidepressant therapy. Afflicting at least half of adults with major depression, it calls for special treatment, often a third course of treatment, an alternative antidepressant or combination with a second antidepressant therapy, along with counseling, psychotherapy or lifestyle changes. To support affected workers, employers should ensure their health and short- and long-term disability coverage provides the necessary benefits, avoids contradictory limits and facilitates return to work as appropriate. Analysis of claims data can reveal TRD and gauge severity. Research by Janssen, Great-West Life and Cubic Health provides incidence data and financial and health metrics that can guide decision making on benefit plan design.

ERISA Fiduciaries Have Duty to Seek Out Readily Available Information.
Benefits Magazine; v52 no4 p 57 Apr 2015; journal article

Availability : International Foundation of Employee Benefit Plans
Abstract : After an initial thoracic surgery the plaintiff in Harrison v. Wells Fargo Bank N.A. et al. required additional, more complicated surgery and, in the same time frame, lost her husband to death, causing severe depression. The defendant employer and health plan rejected her claim for disability benefits. Through two internal appeals, the plaintiff provided documentation from her primary care physician, surgeon and psychologist. The defendant's independent reviewing physician failed to contact the psychologist and recommended denial without supporting records. The plaintiff sued for failure to consider all relevant records and to explain what was needed to complete her claim. The Fourth Circuit Court of Appeals found the defendant violated ERISA Section 503 by falling short of a full and fair review, ignoring medical information and basing its decision on an incomplete record. The case was remanded to the district court for reconsideration.

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