368 F. Supp. 3d 386
D. Conn.2019Background
- Patricia Hughes, a long-term disability beneficiary under a Hartford Life ERISA plan, received benefits beginning 2012 for vestibular disorder and related incapacitating vertigo and migraines.
- Hartford conducted surveillance, medical file reviews, and an independent medical evaluation (Dr. Jares), then terminated benefits in October 2016 and Hughes appealed administratively.
- During the pendency of Hughes's appeal Hartford had her examined by an independent neurologist (Dr. Schiff) and received his report but refused Hughes's requests to receive a copy or to respond before deciding the appeal.
- Hartford relied heavily on Dr. Schiff's report in denying Hughes's appeal on June 29, 2017; Hughes received the Schiff report only after the denial and then filed suit under ERISA § 502(a)(1)(B).
- Court considered whether Hartford's withholding of a plan-commissioned medical report during appeal violated 29 C.F.R. § 2560.503-1's ‘‘full and fair review’’ protections, and whether the procedural violation required remand.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether a plan may obtain and rely on new medical evidence during an administrative appeal without disclosing it to the claimant and without allowing a response | Hughes: regulatory ‘‘full and fair review’’ requires disclosure of and opportunity to rebut any evidence the plan generated or relied on during the appeal | Hartford: ‘‘relevant’’/"benefit determination" in the regulation refers only to documents tied to the initial determination, so no duty to disclose post-initial-review reports before appeal decision | Court: Plan must disclose documents generated/considered in the course of making the benefit determination on review; nondisclosure here denied a full and fair review |
| Whether the regulation's definition of "relevant" and "benefit determination" is limited to initial claim decision | Hughes: terms encompass the entire claim process including appeal; claimant may submit new evidence and have it considered on appeal | Hartford: "relevant" means materials tied to the initial benefit determination; otherwise post-appeal disclosure provisions would be redundant | Court: Interprets regulation to include the appeal-level benefit determination; disclosure duty applies to documents generated during the course of making the benefit determination on review |
| Whether Hartford's procedural violation was harmless or inadvertent so abuse-of-discretion review still applies | Hughes: violation was neither inadvertent nor harmless because decision relied extensively on undisclosed Schiff report, depriving meaningful response | Hartford: argued record should remain closed and court should afford deferential review; opposed consideration of post-appeal rebuttal affidavits | Court: Violation was not harmless; afforded de novo review but remanded for a prompt full and fair reconsideration rather than deciding merits itself |
| Proper remedy when plan fails to provide full and fair review by withholding relied-on evidence during appeal | Hughes: remand to plan for another review allowing disclosure and rebuttal | Hartford: sought denial of relief and deference | Court: Granted remand to Hartford for a speedy, good-faith, full and fair reconsideration; denied defendant summary judgment |
Key Cases Cited
- Halo v. Yale Health Plan, 819 F.3d 42 (2d Cir.) (ERISA procedural requirements and standard of review)
- Abram v. Cargill, Inc., 395 F.3d 882 (8th Cir. 2005) (plan must disclose consultant report used to deny appeal; withholding is improper gamesmanship)
- Salomaa v. Honda Long Term Disability Plan, 642 F.3d 666 (9th Cir. 2011) (failure to disclose consultant evaluations on appeal denied full and fair review)
- Midgett v. Wash. Group Int’l Long Term Disability Plan, 561 F.3d 887 (8th Cir. 2009) (contrary rule limiting disclosure to initial-determination materials)
- Metzger v. UNUM Life Ins. Co. of Am., 476 F.3d 1161 (10th Cir. 2007) (allows withholding if reports contain no new facts or diagnoses)
- Halpin v. W.W. Grainger, Inc., 962 F.2d 685 (7th Cir. 1992) (describes core elements of full and fair review: know evidence, opportunity to rebut, consideration of both sides)