E Point Perfect – Interesting and beneficial content
Law \ Legal

ERISA – 4th Circuit: How Much Weight Do Independent Doctor Paper Reviews Get, and Should Rule 52 Bench Trials Be Used to Resolve De Novo Review Cases

[ad_1]

As you know, the federal circuits have varying approaches to resolving ERISA denial-of-benefit cases. Some circuits use Rule 56 summary judgment as a process to resolve these cases, while the trend has been to use Rule 52 bench trials to resolve cases.

A new case highlights that, in cases applying de novo review, Rule 52 bench trials should be used–especially when there are factual debates on the diagnosis or severity of impairment of a claimant.  

And…how much weight should be given to independent reviews by physicians “who only review the paper record”?  This new case highlights that Independent Medical Exams (IME) may be needed more frequently, at least in the Fourth Circuit, due some overly broad language in the opinion concerning the weight to be given “paper reviews.”

Here’s the case of Tekmen v. Reliance Standard Life Insurance Company, 55 F.4th 951 (4th Cir. December 16, 2022).

FACTS: Tekmen, a financial analyst, sought ERISA-governed long term disability benefits after experiencing a concussion and dizziness, a sensitivity to sounds,  and cognitive dysfunction following an auto accident.  MRIs, EEGs and CT scans were read as normal. Reliance Standard denied the claim after two physicians reviewed Tekmen’s records. While they found some evidence of symptoms of hyperacusis and tinnitus, they found no objective evidence of neurological illness, and concluded “[i]n the absence of specific diagnosis, there is no evidence of impairment.” Tekmen appealed administratively and Reliance Standard then had an otolaryngologist and a psychiatrist review the records and they, too, found no impairment.

Tekmen then filed suit. Both parties filed motions for summary judgment, but then Plaintiff asked the district court to resolve the case under Rule 52. The court heard oral argument on the summary judgment motions and then denied both motions and awarded judgment for Tekmen after conducting a bench trial under Rule 52. Reliance Standard appealed to the Fourth Circuit Court of Appeals.

Fourth Circuit Court of Appeals: AFFIRMED judgment for Plaintiff— KEY HOLDINGS

  1. In de novo review ERISA denial-of-benefit cases, Rule 52 bench trials are the preferred route, rather than motions for summary judgment under Rule 56.

-“[S]ister circuits take diverging views on how ERISA denial-of-benefits cases should be handled….”  Summary Judgment “may be appropriate when there is no genuine issue as to any material fact” and “a bench trial [under Rule 52] is appropriate when fact-finding is required.”  Op. at 13.

-“Ordinarily, in the summary judgment context, the court ‘cannot weigh the evidence or make credibility determinations.’” Op. at 13.

-Some circuits use a “modified summary judgment standard unique to ERISA cases. Instead of  “viewing the evidence in the light most favorable to the non-moving party [as is done in typical Rule 56 motions],” in ERISA cases, the courts in those circuits simply used summary judgment as a vehicle for deciding the issue “and ‘the non-moving party was not entitled to the usual inferences in its favor.’” Op. at 13 (quoting 1st Circuit cases).

-“The difficulty with employing summary judgment in ERISA [cases] arises where the parties disagree as to key facts.”  The Court is then forced to resolve “competing factual contentions within the administrative record about the cause, severity or legitimacy of an individual’s impairment.”  Op. at 13.

-“Where, as here, the district court is faced with directly at-odds contentions regarding whether the individual’s impairment is genuine, we see no alternative to the district court making findings of fact [under the Rule 52 procedure].”  Op. at 14.

-“Accordingly, in the context of de novo review of ERISA denial-of-benefits cases…district courts should employ…[a Rule 52 bench trial], which will typically be limited to the administrative record that was before the plan administrator….”  Op. 15 and fns 5 and 6.

  1. How much weight to give to opinions by treating physicians versus independent record reviews. Reliance Standard argued that the district court erred by giving more weight to the opinions of the treating physicians. The 4th Circuit disagreed, stating:
  • The United States Supreme Court Nord decision “did not create [a rule prohibiting the district court] from giving more weight to the opinions of treating physicians.”  Op. at 18
  • “Where, as here, the district court determines that accounts of treating physicians are more persuasive than those of physicians who only examined a paper record, it is not error for the district court to assign those opinions more weight.”  Op. at 18

Brief analysis: We understand the Court’s directive to use Rule 52 bench trials denial-of-benefit cases, and in practice most district courts in various circuits apply this approach to resolve these cases. However, this Court’s overly broad statement on whether a district court may give more weight to treating physicians versus an independent physician “who only examined a paper record,” should be addressed.  In most cases paper reviews by the independent physician involve a more holistic review of all of the claimant’s records and are much better informed than the siloed review by individual treating physicians. Practitioners should be ready to address this opinion and this overly broad statement. And plan administrators may want to give more thought to having IMEs versus record reviews in certain cases.  

[ad_2]

Source link

Related posts

Guest Post: AI Financial Trading; A Brave New World for Insurers

Successful Brand Awareness for Legal Professionals – Tips from Stefanie Marrone (TGIR Ep. 188)

Fifth Circuit Affirms Striking of Class Allegations

Minnesota Supreme Court recognizes the common interest doctrine

If you never tire of acquitted conduct talk, here is a podcast episode for you

Franchise Renewal Season is Coming so What’s New with FRED?