ERISA–How much weight can the Plan give to surveillance video? How the Plan can lose discretionary review by failing to properly designate claims administrators

more+
less-

Two interesting issues come up in today’s case:

1. An ERISA Plan can lose discretionary standard of review if it failed to properly delegate third parties to make benefit decisions. How do you prove the Plan properly delegated benefit decision-making?

2. How much weight can one give to sporadic surveillance video of a claimant?

Here’s the case of Maher v Massachusetts General Hospital Long Term Disability Plan, [PDF] _-F.3d_ (1st Cir. December 7, 2011) (The Plan must (1) expressly provide for procedures to designate third parties to make benefit decisions, and (2) delegation must actually occur. The Court can look to Plan terms and affiliated documents, like trust documents and the Summary Plan Description to make that determination.)

FACTS: Maher, a nurse at Mass General Hospital(“MGH”), received long term disability ERISA Plan benefits from 2001-2007. The plan contained abuse of discretion language.

Surveillance video and a Doctor’s record review convinced the Plan’s “claim processor” — Liberty — to conclude Maher was no longer “totally disabled.” Maher appealed to Liberty and to the plan administrator — “Partners.” On appeal, different doctors reviewed the claim and concluded disability had not been established. Partners then denied the appeal, and Maher sued.

Please see full article below for more information.

LOADING PDF: If there are any problems, click here to download the file.