Legal Standard of Review for Disability Claims

Published on: May 2, 2011 by

ERISA preempted long term disability insurance, Social Security Disability or Veterans Disability Compensation are the most common benefits available to help disabled workers.  The legal standard of review is the criteria the courts look to in deciding whether to uphold or reverse the rulings of a lower court or in the case of most disability claims, the findings of an administrative proceeding.  This post will explore the legal standard that the disabled worker must meet to prove their claim in court if they are denied during their administrative appeal. 

ERISA PREEMPTED LONG TERM DISABILITY INSURANCE POLICIES

For ERISA Long Term Disability insurance claims, the legal standard of review is abuse of discretion in denying the claim based on the evidence available to the insurance carrier at the time they made the final decision to deny the claim. Generally, the federal court will look at the weight of evidence used to deny the claim and whether or not the insurance carrier’s decision was “reasonable” or if it was “arbitrary and capricious.” The court will not decide whether or not the claimant is disabled or not.

There is an inherent financial conflict of interest for an disability insurance carrier to both decide and pay claims that is recognized by the court. However, if this conflict is found to be heightened by factors including procedural bias, especially by the claims adjuster, reviewing medical professionals or vocational consultants, or other irregularities in the claims process, the court can apply a de novo standard of review, which gives much less deference to the insurance carrier’s decision.

Social Security Disability

Federal courts review the Social Security Commissioner’s denial of Social Security Disability benefits only to ascertain whether: 1) the final decision is supported by substantial evidence and 2) whether the Commissioner used the proper legal standards to evaluate the evidence. In determining whether the Administrative Law Judge’s decision is supported by substantial evidence, the Court weighs four factors: (1) the objective medical facts; (2) the diagnosis and expert opinions of treating physicians on subsidiary questions of fact; (3) subjective evidence of pain as testified to by the Plaintiff and corroborated by family and neighbors; and (4) the Plaintiff’s educational background, work history and present age.

If substantial evidence supports the administrative finding, then the only other potential ground for reversal is the application of an erroneous legal or procedural standard. No deference is afforded the Commissioner’s legal determinations; review of legal issues is de novo.

Veterans Disability

The U.S. Court of Appeals for the Federal Circuit reviews decisions by the U.S. Court of Appeals for Veterans Claims deferentially. Under 38 U.S.C.S. § 7292(d)(1), it must affirm a Veterans Court decision unless it is (A) arbitrary, capricious, an abuse of discretion, or otherwise not in accordance with law; (B) contrary to constitutional right, power, privilege, or immunity; (C) in excess of statutory jurisdiction, authority, or limitations, or in violation of a statutory right; or (D) without observance of procedure required by law. Except for constitutional issues, the appellate court may not review any challenge to a factual determination or any challenge to a law or regulation as applied to the facts of a particular case.

If you have questions regarding the legal standard applied to your disability case, visit us at www.DisabilityDenials.com.