904 F.3d 1
1st Cir.2018Background
- Jane Doe was admitted to the Austen Riggs Center for residential psychiatric treatment in January 2013; her employer-sponsored Harvard Pilgrim plan (HPHC) approved an initial stay but denied coverage for continued residential care after Feb 12, 2013 as not "medically necessary."
- Reviews by UBH/HPHC and an external reviewer (OPP) upheld the denial; Doe nevertheless remained at Riggs at her parents' expense through mid‑June and later had a second admission (which HPHC covered).
- After suit, the parties agreed to a post‑filing administrative review; Doe submitted additional records and expert reports (including Drs. Harris, Plakun, Darrell, Krikorian); HPHC completed the review and again denied coverage on Feb 26, 2016.
- The district court limited the administrative record to materials existing as of the OPP decision (Mar 12, 2013) and excluded Doe’s post‑filing submissions; it applied de novo review and affirmed HPHC’s denial.
- The First Circuit held the parties’ joint agreement to include documents generated or submitted during the post‑filing review made those materials part of the administrative record and thus should have been considered.
- The Court adopted clear‑error review of a district court’s factual findings when the district court conducts a de novo ERISA benefits review, reversed the district court’s record ruling and summary judgment, and remanded for proceedings on the complete administrative record.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Scope of administrative record — whether post‑filing review materials are part of the record | Parties expressly agreed post‑filing submissions would be part of the administrative record; those materials are therefore includable | The OPP decision was the final administrative decision; post‑filing review was settlement‑type or informal and should not alter the final decision or record | Court held the parties’ explicit agreement made post‑filing materials part of the administrative record (final decision concluded Feb 26, 2016) |
| Whether district court properly excluded Doe’s post‑filing evidence | Excluding evidence that was submitted in the parties’ agreed review deprived Doe of consideration of relevant evidence and violated the parties’ representation to the court | District court’s exclusion permissible under precedent limiting supplementation of administrative records after a final decision | Court reversed the exclusion; found ample reason to include post‑filing documents given parties’ agreement and HPHC’s participation |
| Standard of review on appeal of district court’s de novo ERISA factual findings | De novo review by appellate court (as urged by Doe) | Clear‑error review of district court factual findings (as urged by HPHC) | Court held appellate review of district court factual findings is for clear error when the district court conducted a de novo ERISA review |
| Merits (medical necessity) based on truncated record | Doe argued continued residential care was medically necessary and that post‑filing evidence supports reversal | HPHC argued care was not medically necessary based on its reviewers’ opinions; district court had ruled for HPHC | Court vacated merits decision and remanded so the district court can re‑decide on the complete administrative record (no merits ruling by the First Circuit) |
Key Cases Cited
- Orndorf v. Paul Revere Life Ins. Co., 404 F.3d 510 (1st Cir.) (scope of judicial review limited to final ERISA administrative decision)
- Liston v. Unum Corp. Officer Severance Plan, 330 F.3d 19 (1st Cir.) (strong presumption that review is limited to administrator’s record)
- Gross v. Sun Life Assurance Co. of Canada, 734 F.3d 1 (1st Cir.) (remand for reconsideration on supplemented record appropriate)
- Stephanie C. v. Blue Cross Blue Shield of Mass. HMO Blue, Inc., 852 F.3d 105 (1st Cir.) (discussion of standards and procedures for ERISA review)
- U.S. Bank Nat’l Ass’n v. Village at Lakeridge, LLC, 138 S. Ct. 960 (U.S. 2018) (guidance on appellate deference when courts marshal and weigh evidence)
- Tsoulas v. Liberty Life Assurance Co. of Bos., 454 F.3d 69 (1st Cir.) (appellate review of ERISA decisions)