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Deferential Standard Applies to Decision On First Level of Administrative Review

Deferential Standard Applies to Decision On First Level of Administrative Review


ERISA and Life Insurance News
(June 6, 2013)

Harvey sued to recover ERISA disability benefits after Standard Insurance Company affirmed its original claim denial on appeal and before it completed an additional voluntary level of review. In connection with the voluntary appeal, Harvey had submitted additional information, including an award of Social Security disability benefits.

After the district court ruled in favor of Standard, Harvey appealed and made four arguments.

First, she contended that the company’s “failure” to make a decision on the voluntary appeal constituted a “deemed denial” and entitled her to de novo review.

Second, Harvey argued that Standard unreasonably disregarded several pieces of evidence submitted during the voluntary review.

Next, Harvey argued that Standard unreasonably accepted the opinions of “biased” record reviewers over the opinion of her treating physician.

Finally, she asserted that the approval of her short term claim followed by denial of her long term claim demonstrated a conflict of interest.

Rejecting the first argument, the Eleventh Circuit concluded that “Harvey was not denied a full and fair administrative review of her claim as her LTD benefits policy only required one administrative appeal for purposes of exhaustion and the regulations governing voluntary appeals do not provide any time frame for decision-making.” That Harvey did not await the company’s decision on the voluntary level of review before filing suit did not mean that she was entitled to de novo review.

Addressing the second argument, the Eleventh Circuit determined that the district court had properly concluded “that Standard did not unreasonably disregard [the additional documents] as they were not submitted to Standard until after it had rendered a final decision on her administrative appeal . . . .” Instead, Harvey had submitted these documents as part of the voluntary review, the completion of which she chose not to await before filing suit. Only the documents before Standard at the time of the initial review and at the time of the original administrative appeal were relevant, the court held.

Next, the court rejected Harvey’s argument that because the independent reviewers had been paid by Standard, they were “necessarily biased.” The record did not support evidence of bias, the court concluded. The independent reviewers acknowledged the existence of Harvey’s lumbar disc degeneration and scoliosis but determined, along with a vocational consultant, that Harvey could perform sedentary work. Harvey’s physician, by contrast, did not address the question of Harvey’s functional impairment and ability to work.

Finally, the Eleventh Circuit rejected Harvey’s conflict of interest argument based on the approval of her short term claim. Harvey did not explain why the decisions were inconsistent, and the “two forms of benefits are covered under two different policies with two different definitions of disability,” the court reasoned.

Click here to view the full June 2013 Edition of the ERISA and Life Insurance News.

Authors
H. Sanders Carter
T (404) 962-1015
F (404) 962-1220
Kenton J. Coppage
T (404) 962-1065
F (404) 962-1256
Dorothy H. Cornwell
T (404) 962-1096
F (404) 962-1246
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