Previously in this blog, we have examined what the duties and responsibilities of a claimant in the review of a claim, and what are the duties and responsibilities of a Plan Administrator. This case deals with the duties and responsibilities of the court in these reviews.
In this case, the U.S. Court of Appeals reversed the district court’s judgment in favor of the Defnedant and remanded the case in an ERISA action brought by the Plaintiff.
The Plaintiff challenged the Defendant’s denial of her claim for long-term disability benefits. On de novo review, the district court affirmed the Defendant’s denial, but it adopted new rationales that the ERISA plan administrator did not rely on during the administrative process. Specifically, the district court found for the first time that the Plaintiff was not credible and that she failed to supply objective evidence to support the claim.
The Court held that when a district court reviews de novo a plan administrator’s denial of benefits, it examines the administrative record without deference to the administrator’s conclusions to determine whether the administrator erred in denying benefits. The district court’s task is to determine whether the plan administrator’s decision is supported by the record, not to engage in a new determination of whether the claimant is disabled. Accordingly, the district court must examine only the rationales the plan administrator relied on in denying benefits and cannot adopt new rationales that the claimant had no opportunity to respond to during the administrative process.
The Court held that the district court erred because it relied on new rationales to affirm the denial of benefits. As Defendant did not present these rationales during the administrative process, Plaintiff was afforded no opportunity to respond to them, and was denied her statutory right to “full and fair review” of the denial of her claim. The Court reversed and remanded the case to the district court to reconsider the Plaintiff’s claim de novo, with no deference to the administrator’s decision, and to determine whether the record evidence supports the reasons on which the Defendant relied to deny benefits.
If you need assistance navigating your claim for short term or long term disability benefits under ERISA, or it is time to sue the insurance company, please do not hesitate to give Cody Allison & Associates, PLLC a call (844) LTD-CODY, (615) 234-6000. or send us an e-mail Cody@codyallison.com. We provide representation nationwide and have successfully sued all the major insurance companies in many states. Our headquarters are located in Nashville, Tennessee. We offer a free consultation and would love to speak with you.