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Social Security Approval Does Not Mean Disability Insurance Benefits Must be Approved



Attorney Victor PeñaAuthor: Attorney Victor Peña

A common question we receive from claimants is how one can be approved for social security disability benefits but denied private disability insurance benefits. A recent case decided by the 11th Circuit Court of Appeals touched on this issue and reminds us that different disability programs have different standards of determining disability and it is possible to be approved under one standard of disability and denied under another.

In this case, the 11 circuit court of appeals upheld a lower court’s finding that Aetna’s decision to uphold a denial of benefits to a claimant was not wrong.

Mr. Oliver, a FedEx Courier had obtained disability insurance coverage from his employer and following a work injury he received own occupation disability benefits for 24 months. Shortly before the 24 month mark Aetna notified Mr. Oliver that to qualify beyond 24 months he would need to show that he had a complete inability to engage in any compensable employment for 25 hours per week.

Mr. Oliver applied for total disability and was denied. His appeal was also denied with Aetna finding that there was a lack of significant objective findings to substantial his claim for total disability.

Around the time of the denial, Mr. Oliver was notified by the SSA that his SSDI claim was approved. Aetna was notified of the favorable SSA finding but stated in the appeal denial that the SSA determination did not dictate the outcome of Aetna’s review.

Mr. Oliver filed a lawsuit and a federal district court found that Aetna was not wrong.

In reviewing the decision the circuit court upheld the district court’s decision and found that a claimant could not simply rely on the SSA determination to show the administrator’s decision was wrong where the plan’s test for disability differed in several ways and where the plan required significant objective findings.

This case is a good reminder that a finding of disability from the SSA does not mean your disability carrier must also approve your benefits. While the disability carrier is required to consider the SSA finding during its review the SSA standard is different from the standard in most disability insurance policies.

In sum, whether Plan Administrators are required to have your claim reviewed by an independent vocational expert ultimately depends on the language in your particular insurance policy.