You already know that the primary responsibility for providing medical proof of disability undoubtedly rests with the claimant.
But does the plan administrator sometimes have an obligation to obtain medical records and information? YES.
Here’s the case of Harrison v. Wells Fargo Bank, N.A., __ F.3d __ (December 5, 2014) (When there is no evidence in the record to refute the beneficiary’s theory of disability, claims administrators have a duty to obtain materially important records from treaters it knows about, or it must advise claimant what specific records are missing.)
HOWEVER: In cases where there is “sufficient evidence in the existing record to refute claimant’s theory of disability, then a plan administrator is not ‘under a duty to secure evidence [to the contrary]’ under such circumstances.”
FACTS: Harrison sought short term disability benefits under an ERISA plan. The plan granted her benefits during her recovery from a surgery, but denied benefits from September 10 to October 31, 2011 even though she had ongoing complications from surgery and also began experiencing depression. Harrison appealed the denial.
Wells Fargo had two peer reviews—one for her alleged physical disability, and one for her alleged mental disability. The peer review on the mental disability claim never contacted Harrison’s treating psychologist, despite being referred to him. The peer reviewer then concluded “in the absence of psychiatric/psychological records or a telephone conference with her psychologist, an opinion as to whether her psychiatric status limited her functional capacity cannot be provided.” Wells Fargo then affirmed the denial, and Harrison sued.
TRIAL COURT HELD: The Claim was properly denied because there was insufficient evidence of impairment, and Wells Fargo did not abuse its discretion in denying the claim.
ISSUE: Whether Wells Fargo had an obligation to obtain records from treaters it knew about, or should have advised claimant of what specific records were missing?
FOURTH CIRCUIT HELD: REVERSED.
- Wells Fargo failed to contact Harrison’s psychologist even though it was on notice that Harrison was seeking treatment from the psychologist, and had a medical release to obtain information from that treater.
- “While the primary responsibility for providing medical proof of disability undoubtedly rests with the claimant, a plan administrator cannot be willfully blind to medical information that may confirm the beneficiary’s theory of disability where there is no evidence in the record to refute that theory.” Op. at 12.
- “[A]dministrators [must] notify a claimant of specific information that they were aware was missing and that was material to the success of the claim.” Op. at 13.
- NOTE: In cases where there is “sufficient evidence in the existing record to refute claimant’s theory of disability, then a plan administrator is not ‘under a duty to secure evidence [to the contrary]’ under such circumstances.” Op. at 14-15.
- “Nothing in our decision requires plan administrators to scour the countryside in search of evidence to bolster a petitioner’s case…. “[T]here is no open-ended duty…to ‘look all over…for a doctor whose testimony might contradict the medical reports from reliable physicians that ha[ve] been submitted.” Op. at 14.
- In this case, Wells Fargo was “repeatedly put on notice that Harrison was seeking psychiatric treatment.” The record did not refute Harrison’s claim of disability. Op. at 16.
- It was “perfectly reasonable for Harrison to assume” that the plan, armed with the release to obtain records from Harrison’s treating psychologist would have obtained those records for consideration in the appeal. Op. at 18.
- Wells Fargo never made it clear to Harrison that records from her treating psychologist were missing and needed. Op. at 19.
KEY TAKE AWAY: This is an expanding trend in the circuits. When the record does not refute the claimant’s alleged disability, and you are on notice of a treater who may have information related to the claim, either: (1) obtain a release and secure the “readily-available” records, or (2) alert the claimant of what specific records are missing.