Alabama Court Refuses To Consider Additional Medical Evidence Submitted After Metlife’s Denial Of Claimant’s One Mandatory ERISA Disability Appeal

An Alabama Court recently made an interesting and important ruling in an ERISA lawsuit filed against MetLife that prohibited the Court from considering any medical evidence the Plaintiff submitted to MetLife for review after MetLife had already denied the Plaintiff’s one mandatory administrative appeal allowed under the disability insurance policy (the Plan).

What is an “Administrative Record” in an ERISA Disability Case?

We have discussed numerous times that disability insurance lawsuits governed by ERISA differ in many ways from the types of lawsuits we are familiar with and the ones that are portrayed on television and in the media. One of the main differences is what is called the Administrative Record.

In a typical civil lawsuit, for instance, both the Plaintiff and the Defendant can continue to submit evidence to support their position or their claim up until a point just prior to the jury trial. However, in a disability lawsuit filed under ERISA, the ERISA regulation states that the court is only allowed to consider the evidence that the disability insurance company (or the administrator that made the benefit determination) had access to at the time the decision was made to deny disability benefits. That evidence is commonly composed of the applications for benefits, any questionnaires the claimant may have completed for the insurance company, Attending Physician Statement forms completed by the treating physicians, the claimant’s medical records that were either submitted or were obtained by the insurance company during its review of the claim, the Plan documents, sometimes it includes the insurance company’s claim handling procedures and the insurance company’s notes of its investigation, Independent Physician Consultant review reports, Independent Medical Examination reports, and surveillance.

When the disability insurance company first denies your claim for benefits or terminates continued benefits, you are required under ERISA to file an appeal of the denial decision. ERISA requires at least one mandatory appeal, and a maximum of two mandatory appeals, before a claimant is permitted to file a lawsuit against the disability insurance company. After the initial denial, you typically are provided 180 days to file your appeal. The appeal process provides you the opportunity to submit to the disability insurance company any additional medical records, supporting letters from physicians, or any other evidence which you believe supports your claim for disability benefits.

Once the insurance company receives your appeal, they, in turn, have a time frame of 45 days (or they may request additional time up to 90 days) to consider the additional evidence and records you submitted in your appeal, and to perform their own secondary investigation and review of your claim for disability benefits. If your disability Plan only allows for one mandatory administrative appeal and the insurance company upholds their decision to deny benefits after review of your appeal, you are then allowed to proceed to file a lawsuit under ERISA. If your Plan allows for 2 mandatory appeals, if the insurance company upholds the denial after review of the first appeal, you then repeat the process and submit additional medical evidence and records, if you have any.

Once the final decision is made to uphold the benefit denial, the Administrative Record is said to “close”. That means that, according to ERISA regulations, the disability insurance company is not obligated to consider any additional medical or other evidence which might become available after the fact, even if it supports your claim for disability benefits.

Because there are always exceptions to every rule, the disability insurance can, at its own discretion, agree to “voluntarily” review additional records after its final denial. However, any “voluntary” or “extra-contractual” review is not subject to ERISA regulations; meaning there are no time restrictions or other requirements that the insurance company must adhere to because it is basically doing you a favor.

The Court Finds In Favor Of Metlife And Refuses To Consider Medical Records Submitted After The Denial Is Upheld On Appeal

In the Alabama lawsuit against MetLife, the claimant’s disability Plan allowed for one mandatory administrative appeal before the claimant was permitted to file an ERISA lawsuit. MetLife first denied the claimant continued long term disability benefits in November 2008. She appealed the denial and submitted additional medical records in support of her disability claim. MetLife conducted an investigation and reviewed the additional records, and in January 2009, it upheld the decision to deny the claimant continued disability benefits.

In the 2009 denial letter, MetLife specifically informed the claimant that the last review constituted MetLife’s final determination and that the claimant now had the right, under ERISA, to file a lawsuit.

The claimant retained counsel (not Dell & Schaefer) who requested the opportunity to submit additional records to MetLife in support of the claimant’s claim for benefits. MetLife agreed that it was “willing” to conduct one more review of any additional information and gave a deadline (about 45 days) for the additional materials to be submitted. However, the claimant’s attorney proceeded to submit records, request extensions of time and request that MetLife continue to consider any and all additional records, over the course of the following 2+ years.

Finally, after more than 2 years of sending additional records to MetLife, the claimant filed her ERISA lawsuit and requested for the Court to consider all of the medical evidence submitted up until the time the lawsuit was filed.

The Court determined that the claimant’s Plan gave her the right to only one appeal of an adverse disability benefit determination. The claimant did not dispute that MetLife, in fact, provided the appeal and timely resolved it. The Court further determined that ERISA “did not impose a continuing duty on the part of MetLife to consider and review whatever additional evidence Plaintiff might furnish after MetLife had timely denied her appeal on January 30, 2009.” ERISA regulations provide these appeal requirements to protect both the claimant, and the disability insurance company, from “continuous cycles of appeals.”

The Court concluded that its review would be limited to consideration of MetLife’s January 2009 denial of the claimant’s administrative appeal and that it would review only the documents that MetLife had before it at the time of that denial decision.

The Administrative Appeal Is Your ONE Chance To Submit Evidence To Support Your Disability Claim

We learn from this Alabama ERISA lawsuit, that it is absolutely vital to your claim for disability benefits, and any potential lawsuit that may have to be filed in the future, that your Administrative Appeal must be not only strong in support of your claim, but it must also contain or attach as much medical evidence as you can put together in the 180 day window that you are provided. If your Plan only requires one administrative appeal before filing a lawsuit, then this appeal is your only chance to argue your case and also to enter into the Administrative Record any records or evidence that you want the Judge to be able review, should a lawsuit have to be filed.

Because you may only have this one chance, and because disability insurance Plans and the ERISA regulations can be overwhelming and confusing for most, it is important to consult a qualified disability attorney with ERISA experience to assist you in this process.

If you have questions regarding your claim for disability benefits, or if your disability claim has been denied, feel free to call Disability Attorneys Dell & Schaefer for a free consultation.

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