Court Blocks Plaintiff's Attempt To Investigate Medical Valuer's Claims Review History |  Hinshaw & Culbertson - The LHD / ERISA advisor

In Adkins v. Life Insurance Company of North America, 2021 US Dist. LEXIS 37847 (ED, Washington, March 1, 2021), a district court in Washington blocked a plaintiff’s attempt to uncover the claims history of an insurance company’s medical examiner.

While ERISA cases are generally limited to the administrative file, courts may allow parties to conduct limited investigations to clarify the appropriate standard of review or to address conflicts of interest. The Adkins court ruled that the discovery of a medical examiner’s story was inadmissible. In particular, the court refused to order the Life Insurance Company of North America’s (LINA) to disclose how many files one of their medical advisors reviewed for this and how much LINA paid the appraiser’s employer for their services.

In Adkins, Carrie Adkins, who was insured under an ERISA plan (plan) offered by her employer, claimed she was disabled after a car accident in January 2016 due to neck, back and shoulder pain, as well as traumatic brain injury symptoms. Adkins filed a request for LTD benefits, which she backed up with medical records that included reports from two psychologists who concluded that she suffered from cognitive and communication deficits as a result of her injuries. LINA’s claims review included a statement from a clinical psychologist who found that Adkins was not cognitively impaired.

After exhausting her administrative legal remedies, Adkins filed a federal lawsuit in which she was entitled to benefits under ERISA Section 1132 (a) (1) (B) and a right to breach of fiduciary duty under Section 1132 (a) (3) asserts. The parties agreed that the claims were examined de novo. Nonetheless, Adkins proposed a discovery to seek information about the number of claims LINA’s psychology peer reviewer made for LINA and the amount of money LINA paid to their employer. Adkins argued that this discovery, although outside of the administrative record, should be admissible as it was relevant to the plaintiff’s allegation of breach of duty. The court ordered LINA to disclose from 01/01/2019 to 12/31/2020 the amount of money that was paid to the psychologist via third-party providers and how often she was hired.

LINA filed a petition for review of the court order, arguing that obtaining the requested information was neither possible nor practicable due to the way their files were being held, and that the petitioner had demonstrated no exceptional circumstances in order to obtain information outside of the administrative files about the Novo review.

While this litigation was pending, the parties only filed counter motions to ruling on the Administrative Protocol on (a) (1) (B).

On March 1, 2021, the court issued an order in favor of LINA denying plaintiff’s (a) (1) (B) claim to LTD benefits. On the same day, the court also granted LINA’s reconsideration, as the plaintiff admitted in the determination hearing that her claim for breach of duty of loyalty is likely to depend on the success of her claim to benefits, which the court refused. The court found:

The court accepts the defendants’ allegation that they would not keep the requested information and would have to perform a physical review of every lawsuit filed during the timeframe in question to determine if [the psychologist] was involved and how much her employer was paid for her services. Even then, such a process would not disclose the precise relevant information that the plaintiff is looking for. The Court considers such a procedure to be too expensive and time-consuming, as it is easier to obtain information directly from [the psychologist] or your employer.

Also of interest in this case was the court order on the claim of plaintiff (a) (1) (B). In the factual findings of the court and under de novo review, the court fully recognized the opinions of LINA’s medical experts and discredited the opinions of the plaintiff’s doctor. In that ruling, the court performed a detailed analysis of whether the opinions expressed on both sides were consistent with the records of the official visits, tests and overall medical evidence.

The central theses

This case is important to plan administrators as it demonstrates the value of well-founded medical evaluations and also shows that successful investigations into medical evaluators can be successful if it is convincingly argued that the information cannot be readily obtained through the plan.