In Martinez-Claib v. Business Men's Assurance Co. of America and Met. Life Ins. Corp., 2009 U.S. App. Lexis 23074 (11th Cir.), the Eleventh Circuit held that post-hoc arguments or explanations for a claim decision are permitted in cases governed by the de novo review. The Court held that the bar to post-hoc explanations is limited to cases where a court is reviewing the adminstrator's decision under the deferential arbitrary and capricous standard of review.

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Golden Gate Association v. City and County of San Francisco (Case No. 07-17372, 9th Cir. March 9, 2009) involves a challenge on ERISA preemption grounds to a San Francisco law requiring all employers in the City to make mandatory contributions toward employee healthcare costs. The 9th Circuit reversed a District Court ruling that the law is preempted by ERISA. In denying Golden Gate's en banc rehearing petition eight Circuit Court Judges dissented from the court's decision not to rehear this matter en banc and issued a long opinion discussing why the majority is wrong. There's also a concurring opinion defending the majority's decision not to rehear the case. This decision creates a circuit split with the 4th Circuit's decision in Retail Industry Leaders v. Fielder case preemption issue holding that a Maryland state law imposing a similar employer mandate (albeit, only on employers of 10,000 or more employees in the state) was preempted by ERISA. Now that the Circuit Court denied rehearing, the matter is ripe for a petition for certiorari to the U.S Supreme Court.

 

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Objective Medical Evidence

Posted on March 27, 2009 07:54 by Kristina Pett

In Creel v. Wachovia,2009 U.S. App. Lexis 1733(11th Cir. Fla. Jan. 27, 2009), the Eleventh Circuit reversed the grant of summary judgment in favor of Wachovia on the grounds that the plan did not specify the exact type of objective evidence required to support a claim of disability even though the plan provided a list of evidence required including "other forms of objective" evidence."

According to the Eleventh Circuit, Creel provided chart notes, diagnoses, and lab reports from multiple doctors identifying her migraines as physically-based, all of which were valid forms of OME under the plan and could serve as a basis for a diagnosis of migraines. Those documents, particularly those from two doctors, indicated she suffered from debilitating headaches, which had a neurological basis. Creel’s headache diary, as requested by Wachovia, corroborated the diagnosis of migraines and chronicled the degree to which they incapacitated her at regular albeit unpredictable, intervals. In addition, Wachovia never requested an independent medical examination (“IME”).

In assessing the reasonableness of the denial of benefits that involve some subjective elements such as migraines, the Eleventh Circuit Court explained that if the plan has no requirement that claimants provide a specific type of OME, the Court evaluates the reasonableness of the decision in light of the sufficiency of the claimant’s subjective evidence and the administrator’s actions. If the claimant has put forth ample subjective evidence, the Court looks at what efforts the administrator made to evaluate the veracity of the claim, with particular focus on whether the administrator identified any OME that would have proved the claim and on types of IMEs conducted.

The grant of summary judgment based on the conclusion that the plan permitted the administrator to require the claimant to produce objective evidence of her migraines was vacated and the case was remanded. Although, the Court found reversal was proper; it also determined that the record was insufficient to determine whether the migraines prevented Creel from performing any work. On remand, the district court could examine the extent to which the claimant was limited by her headaches.

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