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The Wagner Law Group Description 

The Wagner Law Group, A Professional Corporation, is a nationally recognized ERISA & employee benefits, estate planning, employment, labor & human resources practice. 

 

Established in 1996, The Wagner Law Group has 22 attorneys engaged exclusively in employee benefits, estate planning and employment law. Six of our attorneys are AV rated by Martindale-Hubbell as having very high to preeminent legal abilities and ethical standards. The firm is among the largest ERISA boutiques in the country. Our practice is national in scope, with clients in more than 40 states and several foreign countries.

 

 

 

 

 

Contact Info

The Wagner Law Group

 

  Integrity | Excellence

  

Massachusetts Office 

Tel: (617) 357-5200 

Fax: (617) 357-5250 

99 Summer Street 

13th Floor

Boston, MA 02110


Florida Office 

Tel: (561) 293-3590
Fax: (561) 293-3591
7108 Fairway Drive
Suite 125
Palm Beach Gardens, FL 33418

   

San Francisco Office

Tel: (415) 625-0002

Fax: (415) 358-8300

315 Montgomery Street

Suite 904

San Francisco, CA 94104

 

www.wagnerlawgroup.com

 

 

 

 

January 16, 2015

 

 Health and Welfare Law Alert

 

 

 

Fourth Circuit: Plan Administrators Must Obtain Readily Available Information for Claims Determination   

 

 

 

The Fourth Circuit Court of Appeals has provided guidance on a plan administrator's obligation under ERISA to seek and obtain information relevant to a participant's claim when the participant has not directly provided the information. In Harrison v. Wells Fargo, the Fourth Circuit overturned a plan administrator's decision to deny a participant's claim for short-term disability benefits, finding that there was readily available evidence confirming the participant's claim of disability despite the participant's failure to include the evidence in her claim.

 

Background. In Harrison, the plaintiff underwent surgery to remove a large mass that had extended into her chest, causing pain and tracheal compression. She was unable to work and received short-term disability ("STD") benefits under her employer's ERISA-covered plan. While recovering and waiting for a second surgery, her husband died unexpectedly, triggering a recurrence of depression and post-traumatic stress disorder ("PTSD") related to the death of her children a few years earlier.

 

Three weeks after her first surgery, the plan administrator determined that the plaintiff had recovered and discontinued her STD benefits. The plaintiff filed a claim for reinstatement of STD benefits due to depression and PTSD, but the employer denied this claim. The plaintiff then filed an administrative appeal which included documentation from her treating physicians and a letter from her primary caregiver. In the appeal, she disclosed that she was also receiving treatment from a psychologist and provided the psychologist's contact information.

 

The employer sent the appeal for an independent peer review. The peer review physician contacted the plaintiff's primary care physician, but did not contact the psychologist. The peer review concluded that, in the absence of psychological records, it could not determine whether the plaintiff's psychiatric status limited her functional capacity. As a result, the employer denied the appeal and upheld the benefit denial.

 

The plaintiff next filed a lawsuit against the employer for benefits under ERISA. The district court found that there was insufficient evidence of disability and that the employer did not abuse its discretion in denying the plaintiff's claim. The plaintiff appealed to the Fourth Circuit.

 

Fourth Circuit. On appeal, the Fourth Circuit reversed the lower court and remanded the claim for further review. The Fourth Circuit found that the employer had failed to contact the plaintiff's psychologist even though it was on notice that she was seeking psychological treatment. The Fourth Circuit held that, by not contacting the plaintiff's psychologist the employer chose to remain "willfully blind" to readily available information that may have confirmed her disability.

 

The Fourth Circuit confirmed that ERISA requires a plan administrator to use a "deliberate, principled, reasoning process" in claims determination. The court noted that this does not require plan administrators to "scour the countryside in search of evidence" to bolster a participant's claim. However, the court indicated that where potentially relevant information is available, ERISA does not permit an administrator to "shut his eyes" to that information.

 

Action Steps for Employers. In the wake of Harrison, plan administrators are advised to seek out all readily available information in the claims determination process, even where the claimant has not provided it as part of the original claim or appeal. Failure to do so could result in a court determining that the administrative claims process was deficient. 

 

  

 

 

 

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This Newsletter is provided for information purposes by The Wagner Law Group to clients and others who may be interested in the subject matter, and may not be relied upon as specific legal advice.  This material is not to be construed as legal advice or legal opinions on specific facts. Under the Rules of the Supreme Judicial Court of Massachusetts, this material may be considered advertising.