Opinion ID: 770872
Heading Depth: 3
Heading Rank: 1

Heading: Appellant's Social Security Disability Litigation And Other Prior Medical Evidence

Text: 20 Appellant's first argument is that the lower court erred in finding no ERISAviolation because she has been collecting Social Security disability benefits since 1990 based on the same disability for which she received benefits from appellee up until February of 1996. She argues that this demonstrates the unreasonableness of appellee's noneligibility determination. 21 Appellant's argument falls short of the mark, for two principal reasons. First, we have before suggested and today hold that benefits eligibility determinations by the Social Security Administration are not binding on disability insurers. See Doyle, 144 F.3d at 186 n.4. The criteria for determining eligibility for Social Security disability benefits are substantively different than the criteria established by many insurance plans, including the plan in this case. See generally 42 U.S.C. § 416(i), 423(d). Consequently, although a related Social Security benefits decision might be relevant to an insurer's eligibility determination, it should not be given controlling weight except perhaps in the rare case in which the statutory criteria are identical to the criteria set forth in the insurance plan. 22 Second, and more important in this case, the conclusions reached in appellant's social security litigation date from 1992. Appellee does not contest that appellant was disabled at that time; to the contrary, it concedes such disability. ITT Hartford's reason for terminating appellant's benefits was a lack of evidence that she remained disabled in February of 1996. On that issue, the social security litigation is singularly uninformative, because, although appellant continues to receive social security disability benefits, no review of her eligibility has been undertaken since 1992. 23 The same is true of nearly all of the medical evidence submitted by appellant that tends to support her disability claim. The majority of documents that she submitted to the appellee and to the court date from well before the termination of her benefits in 1996; they range from documentation of the initial determination of her disability in 1990 to comments from physicians prepared as late as 1994. The only favorable evidence arguably within the relevant time period consisted of a statement of disability by her treating physician, Dr. Calvo, in June of 1995, and further comments from the same physician in December of that year. Included in the December comments of Dr. Calvo, however, was his own suggestion that appellant undergo an IME by an orthopedic or rehabilitation specialist chosen by appellee. This would tend to bolster the reasonableness of ITT Hartford in demanding such an examination. In light of the other evidence, Dr. Calvo's mixed comments from June and December of 1995 are simply not enough to create a genuine dispute as to the reasonableness of ITT Hartford's termination decision. 24