A district court in Pennsylvania handled a Long Term Disability case with common sense, meaningfully applying case law relating to procedural irregularities and conflict of interest. This is NOT common practice and worth naming, as ERISA attorneys and claimants know very well. The Court provided a neat list of claim behaviors, taken from other rulings in the Third Circuit (no doubt via Plaintiff’s attorney and ERISA colleague Kirk Woglemuth), that reveal arbitrary behavior by an insurer/claims administrator that include: reversing a decision to award benefits without new medical evidence to support the change in position, relying on the opinions of non-treating over treating physicians without reason, failing to give specific reasons for the denial, conducting self-serving paper reviews of medical files, failing to address all relevant diagnoses before terminating benefits, relying on favorable parts while discarding unfavorable parts in a medical report, denying benefits based on inadequate information and lax investigatory procedures and failing to consider the claimant’s specific job requirements under an “own occupation” policy. If you are an LTD claimant, these tactics will feel all too familiar, as they are regular claim handling “techniques”.
A highlight in the Court’s analysis was finding that the insurance company, Reliance, acted arbitrarily in seeking additional medical evidence from the claimant only a day after Reliance’s own nurse found the claimant to be disabled.
Once in a while, reason rears its head in ERISA opinions, and we all win.
Part of this decision makes the point that ERISA’s strict evidentiary/discovery rules work both for and against claimants. Reliance attempted to submit an affidavit from an employee explaining why it sought the above noted additional medical evidence, but the Court would not consider the explanation since it was outside of the insurance company’s administrative record, the scope of allowable evidence (generally) in an ERISA claim.
LEO NOGA v. RELIANCE STANDARD LIFE INSURANCE COMPANY, No. CV 18-3455, 2019 WL 4034758, at *8 (E.D. Pa. Aug. 27, 2019)
While such evidentiary rules continue to pose significant challenges for ERISA claimants and their attorneys, the courts are beginning to create some fairness around this issue in recognizing that an insurance company must at least provide a complete record. In a district court case out of Illinois, while the Court found that the Plaintiff could not engage in discovery with regard to illumination of the administrative record, the Court, per the Code of Federal Regulations, held that the Defendant had to provide a complete un-redacted administrative record versus the one it attempted to provide to the Plaintiff.
MARY ERIN MILLER v. AMERITECH LONG TERM DISABILITY PLAN, No. 07-2119, 2008 WL 11460692, at *2 (C.D. Ill. May 16, 2008)
Every now and then. ☺