You may have an employment benefit that your employer provided, which was subject to ERISA. Perhaps it is a disability benefit, a life insurance or accidental death benefit, medical insurance benefits or a pension or 401(k) benefit – any ERISA benefit plan. You submitted your claim for benefits and an administrator denied it. You then submitted an appeal as the plan allowed. Once again, an insurer or agency denied it, too. Your remedy, after all your appeals have been denied, is to file suit in court to require your benefit plan to provide promised benefits.
What kind of lawsuit do you get? A lawsuit for ERISA benefits does not entitle you to a jury trial. Rather, a judge will decide whether you are eligible for benefits on the basis of an administrative record. Usually, you cannot submit new evidence in court: With some exceptions, the only evidence a judge usually considers is the evidence that a claimant submitted during the claim and appeal process.
A court case highlighting administrative records
So what is this administrative record that the judge uses to decide whether or not you get your benefits? Who decides what is in that administrative record? A lawsuit that addressed that question was Walker v. AT&T Benefit Plan, No. 3, 2021 WL2623231 (C.D. California June 24, 2021). In this case, our firm represented an AT&T employee seeking long-term disability benefits. The employer initially granted Mr. Walker’s benefits, and then terminated them. He submitted an appeal to AT&T’s claims administrator, Mr. Sedgwick. AT&T again denied that claim. We then filed suit on behalf of Mr. Walker.
The court required AT&T to prepare the administrative record – the record of the documents it used and relied upon or documents that were relevant to its claim decisions. AT&T (and likely Sedgwick) initially prepared an administrative record of 1,256 pages. We thought the record was incomplete, so we requested that AT&T produce additional documents which we believed should have been part of the administrative record. AT&T did not want to do so. Therefore, AT&T filed a motion with the court seeking a protective order to prevent us from obtaining any of the additional documents we had asked AT&T to provide.
Why our client won the case, according to the judge
The judge ruled in favor of our client. The judge explained that the administrative record, properly defined, comprises all documents, records, and other information relevant to a plaintiff’s disability benefits claim. The record should include documents that decision-makers relied upon in making the benefit determination, documents submitted, considered, or created while making the benefit determination whether or not they were relied upon, and documents that show that the plan follows proper procedures.
As the judge ruled, if you do not get the complete administrative record consisting of all relevant documents, “ERISA plan administrators could cherry-pick evidence that supports the denial of a claim when compiling the administrative record – and all but guaranteeee victory in every ERISA benefits case – since the district court’s abuse-of-discretion review would…be strictly confined to that one-sided evidence.”
The judge explained that “requests for discovery that go to the completeness and accuracy of the administrative record should be incontestable – even if they lead to the disclosure of information beyond the bounds of the ‘record’ that defendants produced so far. After all, no court can intelligently review a benefits determination for reasonableness – even under a deferential abuse of discretion review – is not objectively complete, accurate, and created in accordance with ERISA regulations.” The court, therefore, denied AT&T Benefit Plan No. 3’s Motion for Protective Order and ordered AT&T to properly respond to the discovery in question. Thereafter, AT&T produced 2,171 additional pages of documents for the administrative record.
Getting a complete administrative record as full evidence for an appeal
If you have an ERISA benefits claim and your claim is denied and you have to file suit, you will invariably have to make the plan or insurance company provide the complete administrative record. The plan or insurance company will not want to do so and likely will not do so, voluntarily. Being selective about the documentation all but guarantees the plan or insurance company victory in litigation.
If you have an ERISA benefits claim, the ERISA Law Center will fight for you to get your benefits, including fighting to ensure a complete administrative record in the lawsuit.