Did you know that awarding at least some benefits, rather than denying benefits entirely, helps prove the claims administrator is “unbiased”?
Also, when there are sharp conflicting opinions between the claimant’s doctors and claims administrator reviewing doctors, the claims administrator may be entitled to greater deference….
Here’s the case of Cannon v. Aetna Life Ins. Co., __F.3d__, 2013 WL 527655 (D. Mass September 17, 2013) (“when the medical evidence is sharply conflicted, the deference due to the plan administrator’s determination may be especially great.’”)
FACTS: Cannon was a pharmacist, eligible for disability benefits under his employer’s ERISA Plan. The plan conferred discretionary authority to Aetna to determine entitlement to benefits. There was a structural conflict—Aetna funded the plan benefit and made benefit determinations. Cannon filed a short term disability (STD) and long term disability (LTD) for exhaustion and heart arrhythmias. Aetna granted benefits for a period of time, but based on a medical review and peer reviews, Aetna then discontinued benefits. Cannon sued and claimed Aetna ignored records.
Dist. Court Held: Case remanded for further review (but there were some nice pearls in the opinion).
1. “A decision to award at least some benefits rather than deny benefits entirely ‘manifests an approach demonstrating an unbiased interest that favor[s the claim applicant], making the conflict factor less important (perhaps to the vanishing point).’” Op. at 6. (Emph. Added)
2. In ERISA cases, “when the medical evidence is sharply conflicted, the deference due to the plan administrator’s determination may be especially great.’” Op. at 8 (citing Leahy v. Raytheon Co., 315 F.3d 11, 19 (1st Cir. 2002).
3. An expert retained by the claim administrator stated that it would be “beneficial” to review additional records. The Court remanded to Aetna to allow review of those additional records. Op. at 9.
4. A word about the statutory penalty claim (failure to provide plan documents): Claimant must demonstrate “a connection between Aetna’s procedural misstep [in failing to provide requested documents] and his inability to have a full and fair review of the claim to benefits[.]” Op. at 10.