Nov. 10, 2021
- Case governed by DOL regulations that have since been updated
- Claimant entitled to see doctor reports related to her claim
United of Omaha Life Insurance Co. mishandled a legal assistant’s claim for disability benefits by denying her an opportunity to review and respond to a doctor’s report it relied on in terminating her benefits, the First Circuit ruled Wednesday.
United erred in failing to show Karen Jette a report from the doctor who examined her in connection with her appeal challenging United’s decision to terminate her disability benefits, the U.S. Court of Appeals for the First Circuit said. This failure deprived Jette of a “full and fair review” of her benefits claim under the Employee Retirement Income Security Act, and United must reconsider its decision, the court said.
The court’s ruling interpreted a 2002 Department of Labor regulation requiring benefit plan administrators give claimants a “full and fair review” of their claim, including reasonable access to “all documents, records, and other information” relevant to the claim. This regulation was updated in 2016 to specifically require administrators to give claimants any evidence considered in the course of reaching a final decision, but the change wasn’t yet effective when United issued its final decision in Jette’s case, the court said.
The First Circuit noted that circuits have disagreed on whether the 2002 regulation mandates the disclosure of information like this. The court ultimately followed the Ninth Circuit’s reasoning in Salomaa v. Honda Long Term Disability Plan , which held that a benefit plan failed to conduct a full and fair review when it procured two medical opinions but didn’t disclose them to the claimant before denying his internal appeal.
Jette worked as a legal assistant for Preti, Flaherty, Beliveau & Pachios LLP in Boston. She stopped working in 2013 after experiencing back and spinal pain and undergoing spinal surgery. United paid her disability benefits until 2016, when it determined based on medical examinations, surveillance, and social media monitoring that she was capable of performing her job.
Judge O. Rogeriee Thompson wrote the decision. Chief Judge Jeffrey R. Howard joined, as did Judge Raúl M. Arias-Marxuach, sitting by designation from the U.S. District Court for the District of Puerto Rico.
Jonathan M. Feigenbaum of Boston represents Jette. Pierce Atwood LLP represents United.
The case is Jette v. United of Omaha Life Ins. Co. , 1st Cir., No. 20-1713, 11/10/21 .
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