Does ERISA require Plan Administrators to have my claim reviewed by an independent vocational expert?
Author: Attorney Victor Peña
The answer to this question of course, is, it depends…
Many plans explicitly define disability as an inability to engage in employment for which the applicant is “reasonably qualified by training, education or experience.” This language typically defines the “any occupation” definition of disability. Plans containing this language require Plan administrators to conduct some level of analysis of the claimant’s particular vocational circumstances.
Such language is not universal to all ERISA plans, however. In a recent case out of the Northern District of Illinois, a U.S. District Court held that “ERISA does not impose a blanket requirement on plan administrators to obtain independent vocational expert analysis.”
The claimant, Mr. Edelman, filed suit against Roofers’ Pension Fund seeking disability benefits and arguing that the Fund had erred by failing to conduct a vocational assessment, which according to him, would have confirmed that he lacks the education, skills, or experience necessary to secure sedentary employment.
To support his argument, Mr. Edelman cited several cases in which a denial of benefits was reversed because the plan administrator failed to consider the claimant’s individual vocational characteristics. The court, however, pointed out a material difference between Mr. Edelman’s claim and the cases cited by him – specifically, the court noted that the Plan at issue did not contain certain language which would necessitate an individualized vocational assessment.
The court explained:
“Indeed, many plans explicitly define disability as an inability to engage in employment for which the applicant is ‘reasonably qualified by training, education, or experience’… a plan incorporating this kind of terminology necessarily ‘requires some individuation in the analysis’ of benefits entitlement.”
However, the court went on to explain that where such language is absent courts have upheld a denial of benefits although the plan administrator did not have the claim reviewed by an independent vocational expert.
Since the plan under which Mr. Edelman was seeking benefits did not contain similar language the court concluded that the Plan Administrator was not required to obtain independent vocational expert analysis – or rather, that the Fund’s determination could not be deemed so unreasonable as to compel a reversal of the Fund’s denial.
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.