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Procedural Irregularities in Claim Decision Results in Remand

Procedural Irregularities in Claim Decision Results in Remand

Boyd v. Sysco Corp., 2015 WL 7737966 (D.S.C. Dec. 1, 2015)

ERISA and Life Insurance News
(April, 2016)

Boyd sought mental health/substance abuse benefits under the Sysco Corporation Group Benefit Plan for treatment his son received at a residential rehabilitation program. Boyd filed suit after an internal review and an external review by an Independent Review Organization, which upheld the denial of benefits by the claims administrator.

Boyd asserted that Sysco and its claims administrator did not process the claim on time, denied him a full and fair review by omitting documents from the administrative record, and issued benefit determinations that did not identify medical records or plan provisions on which the decisions were based. Although the Plan conferred discretionary authority, Boyd urged the court to apply a de novo standard of review in light of the procedural irregularities.

The court declined to adopt a heightened standard of review, finding that the remedy for procedural irregularities is to excuse a failure by a claimant to exhaust administrative remedies or to remand the case. The court remanded to the claims administrator to consider the corrected administrative record, relevant plan provisions, and internal guidelines and directed the claims administrator to begin the review process anew.

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