The Administrative Record
In most cases, when a lawsuit is filed to secure long term disability benefits under an ERISA governed policy the only information that a Judge can consider at trial is what is contained in the Administrative Record. The Administrative Record consists of all the information you supply to the insurance company in support of your claim, and all the information generated and collected by the insurance company to evaluate your claim. The Administrative Record typically closes after an insurance company renders a final denial of benefits. What does this mean? It means that you are precluded from adding any additional information to your file that could support your entitlement to benefits after a final denial has been rendered. However, a recent order entered by a federal court Judge in the Northern District of California in the case of Oldoerp v. Wells Fargo & Company Long Term Disability Plan; Metropolitan Life Insurance Company demonstrates that the Administrative Record does not always close following a final denial of benefits under an ERISA governed disability policy.
When additional information can be added to the Administrative Record
First and foremost, it is important to note that the ruling entered in Oldoerp is predicated upon a de novo standard of review at trial. If your lawsuit is being decided under the arbitrary and capricious standard of review then the arguments and rulings contained in the order entered by the Court in Oldoerp would not apply.
In this case Ms. O was attempting, amongst other evidence, to have the favorable ruling from the Social Security Administration admitted into evidence for the Judge’s consideration at trial. MetLife opposed the entry of this information as the Social Security ruling was made one month after MetLife had entered a final denial of benefits. Attorneys for MetLife argued that the information contained in the SSDI claim file would not be probative in determining whether MetLife made an erroneous decision to deny benefits, as the ruling did not exist at the time of MetLife’s final denial. The Court disagreed and noted that under certain circumstances new evidence may be admitted “to enable the full exercise of informed and independent judgment.” Citing applicable case law in the 9th Circuit, the Court went on to state that, “[E]xtrinsic evidence is appropriate when “circumstances clearly establish” that additional evidence is necessary to conduct an adequate de novo review of the benefits decision.” What constitutes an “exceptional circumstance?” According to the Court and 9th Circuit case law, it would include, in part:
- Claims that require consideration of complex medical questions or issues regarding credibility of medical experts;
- The necessity of evidence regarding interpretation of the terms of the plan rather than specific historical facts;
- Instances where the payor and the administrator are the same entity and the court is concerned about impartiality;
- Circumstances in which there is additional evidence that the claimant could not have presented in the administrative process.
With respect to getting the Social Security file into evidence, attorneys for Ms. O, argued it was the last circumstance that applied. The Court agreed with her attorneys and noted that the ruling by the SSA was based on an in-person evaluation as well as a review of medical records and as such could shed new light on Ms. O’s condition during the relevant time period. The Court further stated that the SSDI evidence “potentially bears on whether she experienced functional limitations” during the time MetLife was reviewing her claim, and thus whether MetLife was correct to deny her claim for benefits. As such the Court determined that the SSA record is necessary for an adequate de novo review.
What does this mean for you?
This ruling demonstrates that in very limited situations additional evidence outside of the Administrative Record can be argued at trial. The analysis of the information to be proffered, the applicable standard of review, and the jurisdiction of the court all must be evaluated to determine if the right to add information outside of the Administrative Record exists.
Attorneys Dell & Schaefer have not represented Oldoerp at any stage of her claim. If your claim has been denied on appeal and your only option is to bring civil suit under ERISA, please feel free to contact our Office for a free consultation.