This month’s Friday Five covers cases relating to the exhaustion of administrative remedies set forth only in a denial of benefits letter, the scope of information required to be provided to medical reviewers, whether invasion of privacy claims survive ERISA preemption, the detail required of administrators in benefit denial letters, and the proof required of a plaintiff to establish that a structural conflict of interest impacted a denial of benefits.
- Even Permissive Administrative Appeal Provisions in Benefits Denial Letter Require Exhaustion. In a recent accidental death and dismemberment benefits case, the insurer sought summary judgment on the basis that the plaintiff failed to exhaust administrative remedies. The insurer relied on an appeal procedure set forth in a benefits denial letter, which was not found in the policy or plan and was permissive in nature. The District Court, relying on the Eighth Circuit’s policy for courts to avoid reviewing benefits decisions after only an initial denial and also ERISA’s requirement that plans offer a full and fair review of any denial of benefits, concluded that the appeal provisions in the denial letter must be exhausted prior to litigation. The court reasoned that because the denial letter provided the plaintiff with fair notice of the procedures, the claimant was required to follow them. Yates v. Symetra Life Ins. Co., No. 19-154, 2021 WL 2142433 (E.D Mo. May 26, 2021).
- Insurer Not Required to Provide Every Piece of Evidence to Medical Reviewers. The Eleventh Circuit affirmed summary judgment in favor of the insurer in a long-term disability benefits dispute. Most notably, the appellate court addressed the plaintiff’s argument that the insurer’s review was flawed because the medical reviewers lacked all relevant evidence, including a final letter from the plaintiff’s treating provider. The court found that “there is nothing in the ERISA regulations or our precedent that requires a plan administrator to provide every piece of medical evidence – especially repetitive, conclusory evidence – to the administrator’s independent expert before rendering a final decision.” The Eleventh Circuit reconfirmed that insurers have some leeway as to what information is provided to medical reviewers in support of their benefits decisions. Campbell v. Reliance Standard Life Ins. Co., No. 20-13393, 2021 WL 2099810 (11th Cir. May 25, 2021).
- Court Refuses to Allow the Plaintiff to Assert Creative State Law Claims in Benefits Dispute. The plaintiff, proceeding pro se, filed a number of counts related to the termination of his long-term disability benefits. Some of the plaintiff’s more creative claims alleged that the insurer invaded his privacy by hiring private investigators to review his social media and otherwise look into the plaintiff’s conduct. The court found that whether such a claim was preempted under ERISA was an issue of first impression, but granted a motion to dismiss the claim because the facts as alleged failed to satisfy the elements of an invasion of privacy claim from the outset. The court noted that some courts have allowed certain privacy claims to escape preemption, but declined to evaluate the issue because it could dismiss the claim on other grounds. Wall v. Reliance Standard Life Ins. Co., No. 20-2075, 2021 WL 2209405 (D.D.C. June 1, 2021).
- Administrator Not Required to Explain Interpretive Process Behind Decision to Deny Benefits. In another case, the plaintiff was a sales manager with a dental medical supplies company. His employer created a policy that the sales associates could not pay for entertainment-related activities with healthcare providers being solicited for sales. During his tenure with the company, evidence came to light suggesting that the plaintiff had violated the entertainment expenses policy and, as a result, his employment was terminated. The termination also meant that the plaintiff was not eligible for severance benefits under the employer’s ERISA plan. The plaintiff argued that the employer failed to include in the administrative record evidence as to how the administrator arrived at its conclusion to terminate benefits. The court, however, rejected this position, concluding that ERISA only requires the administrator to provide specific reasons for a denial of benefits, not to document the full reasoning behind the decision or to memorialize the interpretive process that generated the denial. The court concluded that the administrator provided sufficient explanation to allow the plaintiff to understand and challenge the denial. Fountain v. Zimmer Inc., No. 17-323, 2021 WL 2125287 (N.D. Ind. May 25, 2021).
- The Plaintiff Must Do More than Speculate that a Conflict of Interest Impacted a Denial of Benefits. In a long-term disability benefits dispute, the court rejected the plaintiff’s last ditch efforts to rely on a structural conflict of interest to avoid summary judgment. After rejecting the plaintiff’s other summary judgment positions, the court determined that the insurer’s dual review and payment of claims was insufficient to avoid dismissal. Beyond merely asserting that the insurer’s decision as unfounded and, as such, must have been infected with a conflict of interest, the plaintiff failed to provide any real evidence of bias. The court went even further to recite the full and fair review that the insurer had provided, which was additional evidence that the plaintiff was simply speculating on the conflict issue. Archer v. Hartford Life & Accid. Ins. Co., No. 18-1158, 2021 WL 2109113 (E.D.N.Y. May 25, 2021).