Legislative “Disability” Does Not Necessarily Equal Insurance “Disability”

My disability insurance clients often ask me whether being deemed “disabled” under the Social Security Disability Benefits Reform Act, the Family Medical Leave Act, or the Americans with Disabilities Act, necessitates approval of their disability insurance claim. Because I am often asked this question, I thought it worthwhile to blog about.

Although disability insurance companies should (and usually do) take SSD, FMLA, and ADA determinations into consideration when deciding claims, Florida’s highest federal court does not require as much, at least in the ERISA context.¹ In endorsing a disability insurance company’s claim denial, the United States Court of Appeals for the Eleventh Circuit noted as follows:

[The insured] relies heavily upon cases applicable in other contexts, particularly social security disability determinations, to support her appeal, but the rules announced therein are inapposite. For instance, although courts accord special weight to the opinions of a claimant’s treating physician in social security cases, the same rule does not apply to disability determinations under employee benefits plans covered by ERISA. Similarly, while the Supreme Court has explained that a social security disability determination should not take into account the possibility of reasonable employer accommodations, no such rule applies to ERISA benefits determinations. Finally, we have previously explained that even the approval of social security disability benefits is not dispositive of whether a claimant satisfied the requirements for disability under an ERISA-covered plan. The same principle should apply to FMLA or ADA proceedings or determinations.²

Moral of the story? Do not rest on your SSD, FMLA, or ADA laurels when it comes to your disability insurance claim. Given SSD, FMLA, or ADA approval is not dispositive of your disability insurance claim, you need to be on top of your disability insurance claim as if your SSD, FMLA, or ADA approval never happened.

For more on disability, life, health, and long-term care insurance, please check out our website: www.paymyinsuranceclaims.com.

---

¹ ERISA stands for Employee Retirement Income Security Act. ERISA is a federal body of law that governs, among other things, certain kinds of group insurance claims. Federal courts usually interpret and apply ERISA in a draconian, carrier-friendly fashion.
² Kennedy v. United of Omaha Life Ins. Co., No. 12-15057, 2014 WL 775677 at *1, n. 1 (11th Cir. (Fla.) Feb. 28, 2014) (internal citations omitted).