A Federal Court in Louisiana has determined that Met Life failed to provide a long term disability insurance claimant with a full and fair review, where it denied the claimant’s appeal for a different reason that the one articulated in the initial claim decision. The Court determined that the failure to provide a second level of administrative review under these circumstances amounted to a failure to provide a “full and fair” review under ERISA. The Court thus sent the claim back to Met Life to permit the claimant to pursue an administrative appeal of Met Life’s new decision.
Long term disability insurance claimants are entitled to a full and fair review of their claims under ERISA. What that means will often be judge dependent and will vary greatly. However, one court, interpreting the ERISA regulations, has decided that where an administrator changes its reasoning for a claim decision, it must afford a claimant a right to appeal the new ground for claim denial.
Here, Met Life originally denied the claim on the purported basis that the treating physician had cleared the claimant to work eight hours per day – which was actually a mistaken reading of the report. On appeal, the claimant was able to overcome this issue, by showing that Met Life had mistakenly relied on a document in error. However, Met Life then chose to take the position that the claimant failed to provide objective evidence to support that he remained impaired and unable to work in any occupation.
Because of the changed reasoning, Met Life failed to afford the claimant an appropriate opportunity to challenge the basis of the termination, and Met Life failed to provide the claimant with the necessary protections under ERISA to secure a full and fair review.
The Court was not persuaded, however, to grant benefits to the claimant, or to award attorneys fees to the claimant for securing the remand.
Richardson v. Met Life Ins. Co.