“Full and Fair Review” — Okay to Disclose Medical Opinions on Appeal After Appeal Denial

 

What does “full and fair” review during an ERISA appeal mean?

Before the appeal decision is made, does the administrator have to disclose to the claimant medical opinions obtained during an appeal? Not if that opinion merely reaffirms or supplements the basis for the initial claim denial.

Here’s the recent case of Lee v. Hartford Life & Accident Insurance Company [pdf], __F.Supp.2d__, 2013 WL 794061 (D.D.C. March 5, 2013).

FACTS:  Lee received ERISA disability benefits. Hartford discontinued benefits after a medical review.  Lee appealed.  During the administrative appeal, Hartford obtained another medical opinion regarding Lee’s condition.  Hartford denied the appeal because this second medical opinion reaffirmed the accuracy of Hartford’s rationale for its initial denial of the claim. Hartford did not disclose the second medical opinion to claimant until after the appeal was denied.

Lee sued, claiming she was denied a “full and fair” review.

ISSUES:

  1. Whether Hartford denied Lee a “full and fair review” because it did not disclose a medical opinion obtained during the appeal, until after the appeal was denied?
  2. Can the Claimant “supplement the record” before the trial court under such circumstances? NO.

DISTRICT COURT HELD/Rationale:

  1. Under ERISA, “[a]fter the administrator denies the claim, the administrator must provide the claimant with notice of the decision” and ‘“relevant documents generated or relied upon during the initial claims determination [and] prior to or at the outset of an administrative appeal.’” Op. at 3-5.  Thereafter the claimant must be provided with a ‘full and fair opportunity’ to appeal the decision internally. Op. at 3.
  2. If the appeal is denied, the ERISA regulations require a second round of disclosures. “But ‘[c]onspicuously absent’ from this provision ‘is any requirement that the claimant be given the opportunity to review and rebut the health care professional’s conclusion’ before the administrator denies the appeal.” Op. at 5
  3. The ERISA regulations also state “that disclosure is required after an internal appeal is denied.” Op. at 5 (Emphasis in original.)
  4. Hartford did not “sandbag” claimant. Hartford merely used the second medical opinion obtained during the appeal to “reaffirm the accuracy of its initial denial.” Op. at 5. Where the results of additional tests and reviews do not provide a new basis for terminating the plaintiff’s benefits, but merely supplement its initial reasoning there is no requirement to disclose that information until at or after the appeal is denied.  Op. at 5.
  5. Plaintiff could NOT supplement the trial court record with additional documents beyond the administrative record.  “[H]er right to ‘full and fair’ review does not entitle her to supplement the record with new documents resulting in an essentially de novo review by this court on a new record.” (Op. at 5 Underscore Added).