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Participant Has Burden of Proof in LTD Claim

On Behalf of | Mar 28, 2018 |

In Castor v. AT&T Umbrella Plan No. 3, the Sixth Circuit rejected an employee’s claim that the administrator for her employer’s disability plan had violated the DOL’s claims procedure regulations by having her appeal reviewed by several doctors, including the same doctor who had originally denied her claim for benefits.

Law. The DOL has issued regulations that establish the requirements of a full and fair review of claims for benefits made by participants and beneficiaries under employee benefit plans covered by ERISA . One such requirement is that, on appeal, the plan administrator consult with “a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment” who is “neither an individual who was consulted in connection with the adverse benefit determination that is the subject of the appeal, nor the subordinate of any such individual.” These requirements apply to plans providing disability benefits.

Facts. In early 2014, the employee, who had worked as a customer service representative for the employer for 15 years, began dealing with various medical conditions including colostrum difficile, pneumonia, H1N1, atrial fibrillation, congestive heart failure, and anxiety and depression. In view of these ailments, the employee was originally approved for short-term disability benefits. However, these benefits were later terminated based on the opinions of her cardiologist and the plan administrator’s cardiologist that she was no longer physically disabled.

The employee appealed the adverse benefit determination; in response, the plan administrator asked two new doctors to review the appeal. During the internal appeals process, the plan administrator also asked its cardiologist who had originally denied the claim to review the updated case file to see whether his prior opinion had changed.  

Upon reviewing the case file, all of the plan’s doctors confirmed the validity of the adverse benefit determination, and the plan administrator upheld its decision to deny the claim for benefits. The employee responded by suing the employer in federal court, claiming that the plan administrator had violated the DOL’s claims procedure regulations prohibition on consulting the same doctor during the claim and appeal process.

Sixth Circuit. In reviewing the case, the Sixth Circuit determined that the administrator’s actions did not violate the DOL’s claims procedure regulation because it had engaged two new doctors to review the employee’s claims of disability. The Sixth Circuit noted that the DOL claims procedure regulations “neither affirmatively preclude an administrator from seeking additional reviews, nor preclude an administrator from asking the original doctor whether his original opinion had changed in light of new medical evidence.” Accordingly, the Sixth Circuit upheld the district court’s decision to dismiss the employee’s claim on the basis that the administrator’s decision to have the original doctor review the employee’s appeal materials did not deprive the employee of a fail and full review of the adverse benefit determination.

Employer Takeaway. The DOL’s new regulations governing disability claims procedures for ERISA-covered employee benefit plans, which became effective April 1, 2018, do not change the requirement that different doctors must be used at different stages of a benefit claim.