The First Circuit Court of Appeals, in Doe v. Harvard Pilgrim Health Care (“HPHC”), has held that the district court erred in upholding a benefit claim denial because it neglected to enforce an agreement between the parties to supplement the record to include information generated during a post-complaint benefits review.
The plaintiff, a college student who suffered from depression and anxiety, received inpatient treatment for several months during 2013 in a residential mental health facility. She was insured under the her father’s employer-provided group health plan. The defendant, HPHC, subsequently reviewed the plaintiff’s claim for benefits and agreed to cover most of the residential treatment except for a period of time that it determined was not medically necessary.
Following several unsuccessful internal administrative appeals over the denial of coverage, the plaintiff sued HPHC in federal district court. During the litigation process, the parties agreed that the plaintiff would be allowed to complete another internal administrative review of her claim, and that the information generated during that review would become part of the record before the district court.
The litigation resumed after HPHC upheld its benefit denial following the completion of the post-complaint internal administrative review process. The district court ultimately sided with HPHC and granted its motion for summary judgment. However, in reaching this decision, the district court did not consider the additional information provided by the plaintiff during the post-complaint internal administrative review process. In response, the plaintiff appealed to the First Circuit.
The First Circuit reversed the district court’s decision, finding that “the administrative record upon which the district court based its findings should have been supplemented.” The First Circuit noted that HPHC “explicitly agreed – twice in a two-page document” that information submitted or generated as part of the plaintiff’s pending administrative review would be included in the record before the court. Accordingly, the First Circuit held that neither First Circuit precedent nor ERISA precluded the district court from enforcing the agreement.