This month’s Friday Five covers cases relating to claims handling and the standard of review, as well as the proper parties to litigation.

1. Does using the same physician for initial claim review and appeal violate ERISA regulations? The Sixth Circuit Court of Appeals examined regulations that require plan administrators on appeal of a denied claim to consult a qualified health care professional who was not previously consulted for the initial claim review. The court’s majority held there was no violation when a plan administrator consulted the same cardiologist for both the initial claim review and appeal because the claimant had “shifted her focus” on appeal by claiming benefits based on psychiatric disability as opposed to physical disability. The dissenting judge, however, concluded that failure to consult a different physician on appeal of a denied claim defeats the purpose of the regulation, which is to engage a different physician to opine on the propriety of the initial reviewing physician’s conclusions. Castor v. AT&T Umbrella Benefit Plan No. 3, No. 17-3400, 2018 WL 1470573 (6th Cir. Mar. 26, 2018).

2. Can the grant of discretionary authority be ascertained from multiple plan documents? Courts have held that altering the default de novo standard of review for benefit determinations under ERISA requires “clear” proof in the plan documents that the plan administrator was delegated discretionary authority to determine eligibility for benefits. The Northern District of Illinois held that this “clear” proof may be derived by combining multiple plan documents and that arguably contradictory terms could be reconciled to establish the grant of discretionary authority. Carlson v. Northrop Grumman Corp., No. 13-CV-02635, 2018 WL 1586241 (N.D. Ill. Apr. 2, 2018).

3. Are plaintiffs entitled to discovery of claim management guidelines? The Middle District of Florida held that an ERISA plaintiff is not entitled to obtain discovery of a plan administrator’s written polices or procedures where those guidelines are not part of the administrative record and there is no evidence that the guidelines were relied upon in consideration of the plaintiff’s claim. The court agreed with MetLife that ERISA regulations do not require production of the entire claims management guidelines, but only the guidelines which were actually consulted and used in connection with reviewing a claim for benefits. Because MetLife relied exclusively upon information contained within the governing plan documents and the administrative record, and the plaintiff presented no evidence to the contrary, MetLife was not required to produce its claim management guidelines, and the plaintiff’s motion to compel was denied. Perera v. Metropolitan Life Ins. Co., No. 3:17-CV-195-J-39MCR, 2018 WL 1899041 (M.D. Fla. Apr. 20, 2018).

4. Must a pre-existing condition be previously diagnosed? The Middle District of Florida enforced the terms of a policy which provided that a disabling condition may be pre-existing, even if it had not been previously diagnosed. The court adopted the report and recommendation affirming the denial of plaintiff’s claim for long-term disability benefits, citing the subject policy’s pre-existing condition exclusion. The plaintiff objected to the magistrate’s report on grounds that his disabling condition (drug dependence) had not been diagnosed during the look-back period. However, under the terms of the policy, a diagnosis was not required for the pre-existing condition exclusion to apply. Ferrizzi v. Reliance Standard Life Ins. Co., No. 3:16-CV-1439-J-39PDB, 2018 WL 1866101 (M.D. Fla. Mar. 28, 2018)

5. Can individual employees be sued as fiduciaries? The District of New Jersey dismissed a claimant’s suit against individual employees who handled his claim for long-term disability benefits. The court acknowledged that while claims for wrongful denial of benefits brought under section 502(a)(1)(B) of ERISA are generally asserted solely against the plan as an entity, the statute does not explicitly state that claims cannot be asserted against non-plan defendants. However, as articulated by the Third Circuit Court of Appeals, the only proper defendants in a 502(a)(1)(B) claim are “the plan itself (or plan administrators in their official capacities only).” Moreover, the court found that the claimant had not alleged facts sufficient to establish that the individual defendants possessed discretionary authority regarding the determination of the plaintiff’s eligibility for benefits. The plaintiff’s allegations indicated that the individual employees merely performed “ministerial tasks, such as claims processing and calculation,” which does not constitute a discretionary role. Notably, however, the dismissal of the plaintiff’s claim against the individual defendants was without prejudice. Hocheiser v. Liberty Mut. Ins. Co., No. CV176096FLWDEA, 2018 WL 1446409 (D.N.J. Mar. 23, 2018).