Nancy Harrison v. Wells Fargo Bank, N.A., 773 F.3d 15

Background

Nancy Harrison, a Wells Fargo employee, received short-term disability (STD) benefits after a bronchoscopy and thyroidectomy for a large chest/thyroid mass; benefits were terminated September 10, 2011, as the administrator deemed her recovered from the thyroidectomy.
Harrison informed Wells Fargo she needed a second, more invasive sternotomy scheduled for October 31, 2011; the dispute concerns denial of benefits from September 10 to October 31, 2011.
During this period Harrison experienced severe emotional trauma after her husband’s death and sought mental-health treatment; she provided contact information and signed releases authorizing contact with her treating physicians, including psychologist Dr. Glenn.
Liberty Life (claims administrator) and Wells Fargo commissioned independent peer reviewers for the physical and psychological claims; the psychological reviewer (Dr. Daniel) reported the record was incomplete and that he could not opine without psychiatric/psychological records or contact with Harrison’s psychologist.
The administrator never contacted Dr. Glenn nor specifically told Harrison that Glenn’s records were missing or required to perfect her claim; Wells Fargo upheld the denial after a two-level appeal and Harrison sued under ERISA § 502(a).

Issues

Issue	Plaintiff's Argument	Defendant's Argument	Held
Whether Wells Fargo abused its discretion by denying STD benefits for 9/10–10/31/2011	Harrison: denial was arbitrary because she had continuing physical pain and psychiatric trauma preventing return to work, and the record was incomplete without Dr. Glenn’s records	Wells Fargo: plan requires claimant to provide medical proof; Harrison failed to submit psychologist records so administrator properly denied benefits	Court: Administrator abused discretion procedurally by failing to seek readily available psychologist records or tell claimant they were specifically required; decision reversed and remanded for full and fair review
Whether the claims process satisfied ERISA’s "full and fair review" requirement	Harrison: administrator was put on notice of psychiatric treatment and had contact info and releases, so it had duty to obtain or specifically request those records	Wells Fargo: no duty to "fish" for evidence; claimant bears primary responsibility to submit records	Court: Narrow duty exists—when administrator is on notice of readily available material evidence and the record is insufficient, it must obtain it or clearly request it; Wells Fargo failed that duty
Whether a plan administrator must contact a claimant’s treating specialist when given contact info and a release	Harrison: yes, here it was necessary because the peer reviewer said records were missing and psychologist could bear on functional capacity	Wells Fargo: not required to seek any and all corroborating records absent clear obligation	Held: where reviewer explicitly states record incomplete and administrator has contact info/release, minimal effort to obtain that evidence is required; failing to do so is a procedural violation
Whether denial was supported by substantial evidence on the existing record	Harrison: existing records (surgeries, ongoing pain, increased antidepressant dose, sister’s statement) made this a close case and required further inquiry	Wells Fargo: record lacked psychologist records and other evidence of disability; had reliable basis to deny	Held: Because record was incomplete and not contradicted by sufficient evidence, denial cannot stand without the additional inquiry required by ERISA and the Plan

Key Cases Cited

Booth v. Wal-Mart Stores, Inc. 201 F.3d 335 (4th Cir. 2000) (sets nonexclusive abuse-of-discretion factors for plan-review decisions)
Gaither v. Aetna Life Ins. Co. 394 F.3d 792 (10th Cir. 2004) (administrator cannot be willfully blind to medical information that may confirm claimant’s theory)
LeFebre v. Westinghouse Elec. Corp. 747 F.2d 197 (4th Cir. 1984) (balancing duty to guard plan assets against paying legitimate claims)
Evans v. Eaton Corp. Long Term Disability Plan 514 F.3d 315 (4th Cir. 2008) (requires reasoned, principled decisionmaking and substantial evidence)
McKoy v. Int’l Paper Co. 488 F.3d 221 (4th Cir. 2007) (administrator must use deliberate, principled reasoning process)
Helton v. A.T. & T., Inc. 709 F.3d 343 (4th Cir. 2013) (discusses abuse-of-discretion review factors applied in this circuit)
Berry v. Ciba-Geigy Corp. 761 F.2d 1003 (4th Cir. 1985) (no duty to secure contrary evidence when reliable evidence shows claimant not disabled)
Elliott v. Sara Lee Corp. 190 F.3d 601 (4th Cir. 1999) (claimant cannot prevail when she fails to submit evidence rebutting record showing ability to work)
Quinn v. Blue Cross and Blue Shield Assoc. 161 F.3d 472 (7th Cir. 1998) (claims process requires reasonable inquiry; meaningful dialogue between administrators and beneficiaries)
Booton v. Lockheed Med. Benefits Plan 110 F.3d 1461 (9th Cir. 1997) (ERISA regulation calls for a meaningful dialogue in the claims process)