ERISA: Successfully Opposing Motions to Supplement the Record with Social Security Disability Determinations– the Advantage to De Novo Review

by Lane Powell PC - ERISA Law Blog
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Lane Powell PC - ERISA Law Blog

You already know that in ERISA life, health and disability claim determinations, “‘[i]n most cases…the district court should only look at the evidence that was before the plan administrator at the time of the determination.’”  (There are many exceptions.)

Sometimes during the later lawsuit, the claimant may seek to supplement the administrative record. For example, you might expect motions to supplement the record when the Social Security Administration issues a disability determination after the ERISA claim administrator initially denies the claim.

So, how do you oppose motions to supplement the record when under de novo review?

And…are there situations in which you might agree to de novo review (rather than discretionary review)?  YES.

According to this new case: “an administrator’s obligation to ask for extrinsic evidence under an abuse of discretion standard of review does not necessarily exist under a de novo standard of review, and the court declines to apply such a requirement on de novo review….” (Emph. added.)

Here’s the case of Reetz v. Hartford Life and Accident Ins. Co., 2017 WL 5176705, ___F.Supp.2d ___ (W.D. WA November 8, 2017)(Court denied Plaintiff’s motion to supplement record with Social Security Administration disability determination. “[A]n administrator’s obligation to ask for extrinsic evidence under an abuse of discretion standard of review does not necessarily exist under a de novo standard of review, and the court declines to apply such a requirement on de novo review….”) (Emph. added). (Kudos to my partner Stephania Denton on a very nice win.)

FACTS: Reetz sought ERISA governed disability benefits; Hartford advised Reetz she must apply to the Social Security Administration (SSA) for disability benefits. Reetz’s SSA application was initially denied, and she appealed. While the SSDI appeal was pending, Hartford denied the ERISA disability claim. Two (2) months later SSA granted Reetz’s SSDI disability claim; Hartford later denied Reetz’s appeal of the claim denial.

ISSUE: Whether the Court should allow supplementation of the administrative record with the Social Security Administration Disability determination?

DISTRICT COURT HELD:  Motion to Supplement Record DENIED.

  • Under Ninth Circuit precedent “‘[i]n most cases…the district court should only look at the evidence that was before the plan administrator at the time of the determination.’”  Op. at 4.
  • “Evidence outside of the administrative record is considered ‘only when circumstances clearly establish that additional evidence is necessary to conduct an adequate de novo review of the benefit decision.’”  Op. at 4-5.
  • Those “certain limited circumstances” when the record can be supplemented include:
    •  claims involving complex medical questions,
    •  credibility of experts,
    •  claims involving little or no administrative record,
    •  the need to interpret plan terms,
    •  instances when payor and administrator are the same entity and the court is concerned about impartiality,
    •  when the claimant could not produce the evidence during the administrative process.  Op. at 5.
  • The Court determined that Reetz “could have presented the SSA decision and the hearing evidence during her appeal of the Hartford denial.” Op. at 5.
  •  Reetz argued that Hartford “should have asked for the information.” But the Court noted “an administrator’s obligation to ask for extrinsic evidence under an abuse of discretion standard of review does not necessarily exist under a de novo standard of review, and the court declines to apply such a requirement on de novo review….”  Op. at 7-8.

 

DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

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