Richard v. Fleet Financial Group Incorp. LTD Employee Benefit Plan
(2nd Cir., February 24, 2010)
In an ERISA action, plaintiff challenged the denial of her long term disability benefits due to chronic fatigue syndrome. The Court held that, under a discretionary review, the insurer’s decision to deny benefits was reasonable and supported by substantial evidence. The objective evidence in the administrative record considered by the Second Circuit included surveillance videos, occupational therapy assessment, independent evaluation, independent review of the claims file and statements from her husband.
Plaintiff was denied the use of extra-record evidence to challenge the insurer’s substantive determination. The Court rejected the plaintiff’s argument that the additional information was admissible given the conflict of interest that existed as a result of the fact the insurer both evaluated the claim and paid the benefits. Agreeing that a conflict of interest is a factor to be considered when determining the reasonableness of a decision, the Court held that substantial evidence outweighed any such conflict.
A copy of the Court’s decision can be found here
Kim Whistler and Dan Gerber
https://www.goldbergsegalla.com/attorneys/Whistler.html
https://www.goldbergsegalla.com/attorneys/Gerber.html
Case provided courtesy of Lexis.