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The recent
Geer v. Hartford Life & Accid.Ins.Co.,
2009 U.S.Dist.LEXIS 48332 (E.D.Mich.
June 9), is one of the more
thoughtful and carefully analyzed
discovery rulings issued in the wake
of Metro. Life Ins.Co. v. Glenn,
128 S.Ct. 2343 (2008), which
dealt with the structural conflict
inherent in an insurer's dual role
as claim administrator/payor of
ERISA benefit claims. Although the
court acknowledged "[t]he role of
discovery in the process of weighing
a conflict remains somewhat
obscure," the court nonetheless used
several precedential rulings as a
guide. First, the court cited
Perry v. Simplicity Eng'g, 900
F.2d 963 (6th U.S. Circuit Court of
Appeals, 1990), which found that
while the scope of review in ERISA
cases is generally limited to the
claim file, evidence outside the
so-called "administrative record"
may be considered if that evidence
"is offered in support of a
procedural challenge to the plan
administrator's decision, such as an
alleged lack of due process afforded
by the administrator or alleged bias
on its part."
Then, in
Calvert v. Firstar Finance Inc.,
409 F.3d 286 (2005), the 6th Circuit
noted the potential structural
conflict resulting from an insurer's
dual roles as plan administrator and
benefit payor, and suggested:
"The court would
have a better feel for the weight to
accord this conflict of interest if
Calvert had explored the issue
through discovery. While Calvert's
counsel asserted that it was his
understanding that discovery is
never permissible in an ERISA action
premised upon a review of the
administrative record, an exception
to that rule exists where a
plaintiff seeks to pursue a decision
maker's bias. See e.g. Wilkins
v. Baptist Healthcare Sys. Inc.,
150 F.3d 609, 618 (6th Cir.
1998)."409 F.3d at 293 n.2.
Subsequently, in
Kalish v. Liberty Mutual/Liberty
Life Assur. Co., 419 F.3d 501
(6th Cir. 2005), although no
discovery had been taken, the 6th
Circuit ruled for the plaintiff in a
disability benefit dispute after
finding "an administrator's decision
based on the work of a doctor in its
employ must be viewed with
skepticism." The court remarked,
though, that it had not been
presented with more than a
conclusory allegation of bias, and
there was no specific evidence the
physician "had consistently rendered
opinions favorable to the
administrator." Yet the court
reiterated that discovery could have
been helpful.
Nonetheless, the
court identified a tension in 6th
Circuit rulings — those that suggest
a general right to discovery in
cases involving a structural
conflict, and other rulings allowing
discovery only if the plaintiff is
able to make a preliminary showing
of a due process violation or other
evidence of bias. For example, in
Putney v. Medical Mutual of
Ohio, 111 F.Appx. 803 (6th Cir.
2004), the 6th Circuit affirmed a
district court ruling disallowing
discovery where the plaintiff made
no preliminary showing of bias or a
due process denial. And in
Huffaker v. Metropolitan Life
Insurance Co., 271 F.Appx. 493,
503-504 (6th Cir. 2008), the 6th
Circuit cited Putney as the
basis for its conclusion that in
that ruling, "we determined that a
claimant must make a predicate
showing with respect to an alleged
procedural violation to be granted
further discovery."
Because of the
Glenn ruling, though, since
the Supreme Court directed that the
conflict must always be considered
regardless of whether a showing is
made that the conflict infected the
determination, the court held
discovery would be appropriate. The
court further pointed to Glenn's
finding that the conflict
"should prove more important
(perhaps of great importance) where
circumstances suggest a higher
likelihood that it affected the
benefits decision, including, but
not limited to, cases where an
insurance company administrator has
a history of biased claims
administration." 128 S.Ct. at 2351.
Thus, while not addressing discovery
per se, the Glenn
ruling implies the necessity of
discovery in order for the court to
properly weigh the significance of a
conflict.
However, the
court was also careful to announce
that it rejected the idea that
discovery is automatic merely
because of the "inherent decision
maker/payor conflict." Instead,
discovery would be available only
"where a plaintiff has provided
sufficient initial facts suggesting
a likelihood that probative evidence
of bias or procedural deprivation
would be developed." The court thus
rejected the plaintiff's allegation
that discovery was appropriate on
the issue of whether the insurer
ignored significant portions of the
medical evidence submitted. The
court pointed out that the record
itself would reveal if that were the
case, and "[t]o the extent that
insufficient regard was paid to
material in the record, there is no
need for discovery to demonstrate
that lack of respect." The court
also rejected allowing discovery
based on a bare allegation that
surveillance videos had been
selectively edited; and while the
plaintiff claimed the insurer
disregarded its own standards in
evaluating the claim, there was no
showing as to what standards were
allegedly violated, and thus
discovery on that issue was also
denied.
The plaintiff was
successful, though, in obtaining
permission to obtain discovery in
relation to the physicians who
reviewed the claim file along with
the business relationship between
the insurer and the organization
that hired the reviewing doctors,
University Disability Consortium.
The court further allowed limited
discovery as to the history of
claims made under the policy at
issue over the 10 years preceding
the plaintiff's claim. Also, limited
discovery was allowed as to bias
based on the insurer's apparent
disregard of a Social Security
disability award.
This is not the
first time that courts have allowed
plaintiffs to probe the relationship
between Hartford and University
Disability Consortium, an
organization that works closely with
Hartford in assigning doctors to
review disability claims. In
Jacoby v. Hartford Life and
Accid.Insur.Co., 2009
U.S.Dist.LEXIS 6498 (S.D.N.Y. Jan.
23), the court allowed broad
discovery into that relationship;
and in Caplan v. CNA Financial
Corp., 544 F.Supp.2d 984 (N.D.Cal.
2008), the court permitted discovery
that showed a particular reviewing
doctor had issued reports favoring
denial of disability benefits in 193
out of 202 files reviewed in
slightly more than a two-year
period.
Some of the areas
in which the court denied discovery,
though, seem somewhat surprising.
The insurer denied benefits in part
based on only 10 minutes of
surveillance video taken over the
course of several days. That begs
the question of what may have been
selectively edited out of the video
furnished to Hartford. Indeed, in a
recent ruling, Nash v. Life Ins.
Co. of N. Am., 2009 U.S. Dist.
LEXIS 36285 (N.D.Ill. April 29), the
court compelled disclosure of such
evidence pursuant to a subpoena
issued to the company that performed
the surveillance finding a request
for the outtakes relevant.
Likewise, based
on Glenn's ruling that
insurers evaluating ERISA claims are
to employ "higher-than-marketplace
quality standards" to assure
accurate claim determinations (128
S.Ct. at 2350), it would have been
appropriate to grant the plaintiff
some leeway to depose the claims
personnel to determine whether such
standards were applied, and whether
the insurer's practices may have
been deficient. A prominent attorney
recently wrote a book describing how
cases are won in such a manner. R.
Friedman and P. Malone, Rules of
the Road — A Plaintiff Lawyer's
Guide to Proving Liability
(Trial Guides LLC 2006).
The Supreme
Court's emphasis on accuracy, and
Glenn's citation to
Universal Camera Corp. v.
NLRB, 340 U.S. 474, 490, 71 S.
Ct. 456, 95 L. Ed. 456 (1951), must
also be viewed as significant in
relation to this issue since
Universal Camera explained that
courts must do more than simply
assume the record compiled by an
agency is sufficient based on an
appearance of regularity. Courts
must now take responsibility for
assessing the reliability of
evidence on which the claim decision
is based; and the 6th Circuit has
taken the lead in admonishing that
courts adjudicating ERISA cases are
to assess both "the quality
and quantity of the medical evidence
and the opinions on both sides of
the issues." Glenn v. Metro.Life
Ins.Co., 461 F.3d 660, 666 (6th
Cir. 2006) (citation omitted);
aff'd 128 S.Ct. 2343 (2008)
(emphasis added). The only way in
which courts can adequately perform
that duty in their review of ERISA
claims is to allow discovery.
Note:
My firm was involved in the Nash
case cited in this article.
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