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M.D. Tenn.: Materially Important Information and Substantial Compliance

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  • M.D. Tenn.: Materially Important Information and Substantial Compliance

    In a tragic, yet interesting case out of the Middle District of Tennessee, the court takes a strong stance on substantial compliance with ERISA when relevant, and materially important information is not considered in denying a claim. Here, the Plaintiff was a widow who's husband died on a hunting trip. Initially, the Office of the Medical Examiner determined that his death was caused by suicide. The Defendant denied the Plaintiff's claim on that basis. After multiple extensions of the statutory period to make a decision on the appeal, the Plaintiff notified the Defendant that the ME was reopening the case. On March 11, 2014, the Office of the Medical Examiner completed his review and changed Decedent’s cause of death from “suicide” to “could not be determined.” On March 21, Defendant closed its investigation and denied Plaintiff benefits. On March 31, 2014, the Office of the Medical Examiner certified its Amended Report and Plaintiff’s counsel sent the report to Defendant.

    The court held:

    The primary reason that Defendant did not substantially comply with the regulations is that it did not consider the Amended Medical Examiner Report. In that Report, David L. Zimmerman, M.D., considered three additional pieces of information that were not available when preparing the initial Report, including (1) that the muzzle of the shotgun was at the location of the entrance wound while the butt of the shotgun was on the ground at the time it was fired; (2) the forearm of the shotgun was stuck in a pulled back position, so a malfunction of the shotgun cannot be ruled out; and (3) the hunting trip was “‘spur of the moment’ at the suggestion of another individual.” (Id.) Based on the additional information, Dr. Zimmerman changed the cause of death from “suicide” to “could not be determined.”
    The defendant argued that is substantially complied with the regulations by granting the Plaintiff multiple extensions, and that it is not required to hold an appeal open for an indefinite period of time. The court, however, found that refusal to consider the new ME report violated ERISA:

    when Plaintiff served notice that potentially important information was forthcoming that is directly relevant to her claim, she has a right under § 2560.501-1 for Defendant to hold the record open pending receipt of that information. See Gaither v. Aetna Life Ins. Co., 394 F.3d 792, 808 (10 Cir. 2004) (“An ERISA fiduciary presented with a claim that a little more evidence may prove valid should seek to get to the truth of the matter.”) The Sixth Circuit has looked favorably, without adopting, a rule that the Plan Administrator should locate evidence that is “easily attainable” to a claim. McAlister v. Liberty Life Assur. Co. of Boston, 647 F. App’x 539, 550 (6th Cir. 2016) (compiling cases) (quoting Booton v. Lockheed Med. Benefit Plan, 110 F.3d 1461, 1463-64 (9th Cir. 1997)). The Administrative Record is clear that Plaintiff and Defendant were in constant contact during the appeal, and Defendant’s Appeal Specialist even “appreciated” and “recognized” Plaintiff’s counsel’s “hard work and responsiveness.” Defendant could easily have sent Plaintiff’s counsel an email asking whether Plaintiff still intended to provide the additional information she informed Defendant she would be providing, or asked the Medical Examiner when his supplemental report would be finished. It did neither. As such, the closing of the Administrative Record prior to receiving all known information Plaintiff wished to supply was arbitrary and did not substantially comply with the ERISA regulations.
    The Order as well as the Report and Recommendation are attached below.
    Attached Files
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