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District Court to Consider Information from Post-Complaint Internal
First Circuit Court of Appeals, in Doe v. Harvard Pilgrim Health
Care ("HPHC"), has held that the district court erred
in upholding a benefit claim denial because it neglected to enforce
an agreement between the parties to supplement the record to include
information generated during a post-complaint benefits review.
Background. The plaintiff, a college student who suffered
from depression and anxiety, received inpatient treatment for several
months during 2013 in a residential mental health facility. She was
insured under the her father's employer-provided group health plan.
The defendant, HPHC, subsequently reviewed the plaintiff's claim for
benefits and agreed to cover most of the residential treatment except
for a period of time that it determined was not medically necessary.
several unsuccessful internal administrative appeals over the denial
of coverage, the plaintiff sued HPHC in federal district court.
During the litigation process, the parties agreed that the plaintiff
would be allowed to complete another internal administrative review
of her claim, and that the information generated during that review
would become part of the record before the district court.
litigation resumed after HPHC upheld its benefit denial following the
completion of the post-complaint internal administrative review
process. The district court ultimately sided with HPHC and granted
its motion for summary judgment. However, in reaching this decision,
the district court did not consider the additional information
provided by the plaintiff during the post-complaint internal
administrative review process. In response, the plaintiff appealed to
the First Circuit.
Circuit. The First Circuit
reversed the district court's decision, finding that "the
administrative record upon which the district court based its
findings should have been supplemented." The First Circuit noted
that HPHC "explicitly agreed - twice in a two-page
document" that information submitted or generated as part of the
plaintiff's pending administrative review would be included in the
record before the court. Accordingly, the First Circuit held that
neither First Circuit precedent nor ERISA precluded the district
court from enforcing the agreement.
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