Texas Judge Rules No New Medical Evidence Allowed Post ERISA Disability Appeal
Author: Attorney Gregory Dell
In Hutchings v. Lora Lyons, Plan Administrator, and Ball Industries Employee Injury Benefit Plan, et al. (Defendants), plaintiff Linda Hutchings injured her knee while at work. Her initial request for disability benefits was granted so she could have surgery for a torn right medial meniscus. The surgery was not successful.
Just a few months later, she requested disability benefits so she could have a total knee replacement surgery and her request was denied. Defendants claimed it was a preexisting condition. Hutchings’ administrative appeal was denied and she subsequently filed this ERISA lawsuit. She filed the administrative record at the same time.
A week later, defendants filed additional attachments, including an eight-page report by a medical doctor who had reviewed the plaintiff’s medical records. Plaintiff moved to strike the report since she had never seen it before and it was not part of the administrative record. Defendants objected, claiming the report would be helpful to the Court since it “synthesized” hundreds of pages of medical records.
The Court decided in favor of the plaintiff and held the new report was inadmissible. Plaintiff had never had an opportunity to rebut its contents and it did not fall under any exception to the rule that no new evidence can be submitted after the administrative appeal is finished.
The Medical Report Did Not Fit Under Either of the Two Exceptions That Allow a Court to Consider Evidence Outside the Administrative Record
The District court relied on Fifth Circuit precedent that makes it clear that “when assessing factual questions, the district court is constrained to the evidence before the plan administrator.” There are two exceptions to this rule:
1. Evidence that shows how an administrator has interpreted the terms of the plan in other similar cases.
2. The evidence assists the court “in understanding the medical terminology or practice related to a claim.”
Defendants argued the evidence fell into the second exception and would assist the court in understanding the medical terminology or practice. The court disagreed.
The Medical Report is Not One That Assists the Court in Understanding Medical Terminology
The court noted its job is “to review the record as the Administrator had it when she denied the claim.” It was undisputed that this report was generated nearly a year after the defendants had denied plaintiff’s claim. There was nothing purported to be in the report that would aid the court in understanding medical terminology or practice, but was only a “synthesized” version of her medical records. Accordingly, the court held that its admission would be only “cumulative and unnecessary.”
Plaintiff Did Not Waive her Right to Object
Defendants then argued that Hutchings waited too long to object to the inclusion of the report in the file. The court disagreed with this argument, noting the report was filed nearly a year after the denial of Hutchings’ “employee injury claim.” She made her objection approximately 10 weeks after the 1,000 plus pages of her administrative record was filed with the court, which was a reasonable period. Accordingly, the court deemed her objection was timely and the report was “not properly before the court.” The report was stricken from the administrative record.
This case was not handled by our office, but we believe it can be instructive to those who may be faced with a similar situation. If you have questions about this case, or any question concerning our disability benefits, contact us at Dell & Schaefer for a free consultation.