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Administrator Abuses Discretion by Not Obtaining Information that Could Confirm Plaintiff

Administrator Abuses Discretion by Not Obtaining Information that Could Confirm Plaintiff's Disability

Harrison v. Wells Fargo Bank, 773 F.3d 15 (4th Cir. 2014)


ERISA and Life Insurance News
(May 12, 2015)

Harrison, a customer service representative for Wells Fargo Bank, underwent a thyroidectomy in 2011.  One week after the surgery, she informed Wells Fargo that her condition would require a second surgery approximately two months later.  Before her surgeries, Harrison's husband died suddenly, triggering a recurrence of post-traumatic stress disorder related to the death of her mother and children in a house fire years earlier.  Harrison's primary care physician referred her to a psychologist, Dr. Glenn, for treatment of PTSD.

Wells Fargo's self-funded short-term disability plan entitled employees to salary replacement benefits when "a medically certified health condition" rendered an employee "unable to perform some or all of [his or her] job duties for more than seven consecutive days."  The plan defined "a medically certified health condition" as a disabling injury or illness that is "documented by clinical evidence as provided and certified by an approved care provider … including medical records, medical test results, physical therapy notes, mental health records and prescription records."

After determining that three weeks was the typical recovery period for a thyroidectomy, Wells Fargo paid Harrison STD benefits for three weeks post-surgery,.  Harrison sought continuing STD benefits on the basis of both physical and psychiatric conditions.  In support of a second level appeal, Harrison provided records from her surgeon and primary care physician, as well as a letter from her sister, who detailed Harrison's continuing pain and panic attacks.  She also provided Wells Fargo with contact information for Dr. Glenn\ and a release permitting Wells Fargo to contact any of her physicians.

As a part of its review, Wells Fargo sought two independent medical reviews – one of Harrison's physical disability claim and another of her psychological disability claim.  The physician reviewing the psychological disability claim, Dr. Daniel, contacted Harrison's primary care physician but not Dr. Glenn, the psychologist.  Dr. Daniel concluded:  "In the absence of psychiatric/psychological records or telephone conference with her psychologist, an opinion as to whether her psychiatric status limited her functional capacity cannot be provided."  Wells Fargo thereafter upheld the decision to deny the claim for STD benefits based on a psychological condition.

The federal district court upheld Wells Fargo's claim decision.  The Fourth Circuit reversed and directed the district court to remand the case to Wells Fargo for further proceedings.  The Fourth Circuit held:

By failing to contact Dr. Glenn when it was on notice that Harrison was seeking treatment for mental health conditions and when it had his contact information, as well as properly signed release forms from Harrison, [Wells Fargo] chose to remain willfully blind to readily available information that may well have confirmed Harrison's theory of disability.

The Fourth Circuit reached this conclusion under an abuse of discretion standard of review.

The court acknowledged that a claimant has the primary responsibility for providing medical support of disability, and emphasized that "[n]othing in our decision requires plan administrators to scour the countryside in search of evidence to bolster a petitioner's case."  Citing Gaither v. Aetna Life Ins. Co., 394 F.3d 792 (10th Cir. 2004).

In this case, however, the court found that Wells Fargo was on notice that Harrison was seeking benefits based on psychiatric treatment.  Harrison provided Dr. Glenn's contact information and a release allowing direct contact with all of her physicians.  Wells Fargo then retained Dr. Daniel to conduct an independent medical review.  Dr. Daniel contacted Harrison's primary care physician, but did not take the additional step of contacting Dr. Glenn directly.  The court also noted that the record did not otherwise refute Harrison's claim.

Under these circumstances, the court concluded that Wells Fargo abused its discretion when it neither sought readily available records from Dr. Glenn nor informed Harrison that Dr. Glenn's records were necessary for a full and fair review of her claim.

Click here to view the full May 2015 Edition of the ERISA and Life Insurance News.

Authors
H. Sanders Carter
T (404) 962-1015
F (404) 962-1220
Andrea K. Cataland
T (404) 962-1045
F (404) 962-1255
Kenton J. Coppage
T (404) 962-1065
F (404) 962-1256
Mary B. Ramsay
T (843) 300-6659
F (843) 300-6759
Jennifer Noland Rathman
T (404) 962-1074
F (404) 962-1213
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