Hamburg v. Life Insurance Company of North America
Filing
16
ORDER AND REASONS re 14 Trial Brief filed by Kai Hamburg and 15 Pretrial Memorandum filed by Life Insurance Company of North America. The Court finds that the administrative record is complete. The SSA decision is not a part of it. Briefs on the remaining issues must be submitted not laterthan 8/8/11, as provided for in the pre-trial conference. Signed by Judge Martin L.C. Feldman on 8/1/11.(tsf, )
UNITED STATES DISTRICT COURT
EASTERN DISTRICT OF LOUISIANA
KAI HAMBURG
CIVIL ACTION
VERSUS
NO. 10-3071
LIFE INSURANCE COMPANY OF
NORTH AMERICA
SECTION "F"
ORDER & REASONS
Before the Court are pre-trial memoranda on the issue of
treatment of the administrative record in this ERISA case.
The
parties address the narrow issue of whether this Court should
review a decision of the Social Security Administration which was
never
made
a
administrator.
complete.
part
of
the
record
that
was
before
the
plan
The Court finds that the administrative record is
The SSA decision is not a part of it.
Background
Kai Hamburg, the plaintiff, makes a claim under ERISA for
improper denial of long-term disability benefits under a group
disability
insurance
policy
issued
and
administered
by
Life
Insurance Co. of North America, the defendant.
Mr. Hamburg is a
data control specialist with Tulane University.
He claims that he
became disabled after a work-related car accident on February 16,
2007, which left him with injuries to his neck, back, and right
shoulder.
He also suffers from depression.
Nine months after his accident, the plaintiff submitted a
claim for long-term disability benefits under Tulane's plan with
1
the defendant. The defendant, as administrator, denied benefits on
April 4, 2009, determining that the plaintiff’s injuries did not
render him “disabled” as defined by the plan.
Plaintiff exhausted
all administrative appeals of that decision and then sued the
defendant on September 15, 2010.
Meanwhile, on March 30, 2009, only five days before the
defendant originally denied the claim for benefits, the Social
Security Administration ruled the plaintiff to be disabled.
The
plaintiff claims that he did not know of the SSA decision until
over a year later—yet still months before he filed this lawsuit—and
that he believed the defendant was already in possession of it.
The plaintiff sued, and it was not until preparing for a recent
mediation session that the plaintiff discovered that the SSA
decision was not part of the administrative record.
The parties agree that this case is to be evaluated on the
basis of the administrative record but dispute whether the SSA
decision
should
be
part
of
that
record.
Specifically,
the
plaintiff asks the Court, during its review, to supplement the
record with the SSA decision or, alternatively, to remand the
entire case for the defendant’s belated consideration of the SSA
decision.
The defendant maintains that the administrative record
is complete and that supplementation is improper on the eve of
trial.
The Court agrees.
2
Law & Analysis
The
parties
do
not
dispute
that
the
Court’s
review
is
constrained to the administrative record; to that evidence which
was before the plan administrator in resolving plaintiff’s claim
for benefits; the Court may not open the record and conduct
discovery as to these determinations, or indulge in fact-finding.
See Gooden v. Provident Life & Accident Ins. Co., 250 F.3d 329, 333
(5th Cir. 2001) (noting, as an exception to this general rule, that
a district court may consider evidence outside the administrative
record if it will assist the court in understanding the medical
terminology or practice related to the claim); see also Vega v.
Nat’l Life Ins. Servs., Inc., 188 F.3d 287, 299 (5th Cir. 1999) (en
banc).
However,
both
parties
also
agree
that
in
limited
circumstances, the Court may supplement the administrative record.
The U.S. Court of Appeals for the Fifth Circuit recently
clarified the boundaries of administrative record supplementation
in ERISA cases in Crosby v. Louisiana Health Services & Indemnity
Co., No. 10-30043, 2011 WL 2811532, at *3 (5th Cir. July 19, 2011).
Because under ERISA “[a] plan participant is not entitled to a
second chance to produce evidence demonstrating that coverage
should be afforded,” the Court may not admit “evidence to resolve
the merits of the coverage determination—i.e. whether coverage
should have been afforded under the plan—unless the evidence is in
the administrative record, relates to how the administrator has
3
interpreted the plan in the past, or would assist the court in
understanding medical terms and procedures.”
Id.
Crosby acknowledges that the Court may admit evidence to
resolve other questions that may arise in an ERISA action:
For example, in an ERISA action under 29
U.S.C. § 1132(a)(1)(B), a claimant may
question
the
completeness
of
the
administrative record; whether the plan
administrator complied with ERISA's procedural
regulations; and the existence and extent of a
conflict of interest created by a plan
administrator's dual role in making benefits
determinations and funding the plan.
These
issues are distinct from the question of
whether coverage should have been afforded
under the plan. We see no reason to limit the
admissibility of evidence on these matters to
that contained in the administrative record,
in part, because we can envision situations
where evidence resolving these disputes may
not be contained in the administrative record.
Id.
But, these circumstances are limited by the appellate court’s
repeated implication that if supplementation of the administrative
record is to be permitted at all, it must take place before a
claimant files suit.
See Vega, 188 F.3d at 300 (“Before filing
suit, the claimant’s lawyer can add additional evidence to the
administrative record.”) (emphasis added); id. at 302 n.13 (“We
want to encourage each of the parties to make its record before the
case
comes
to
federal
court.”)
(emphasis
added);
Ewing
v.
Metropolitan Life Ins. Co., No. 10-20668, 2011 WL 2204797 (5th Cir.
June 7, 2011) (upholding the district court’s refusal to supplement
the administrative record with medical records not before the plan
4
administrator); see also Schexnayder v. Hartford Life & Accident
Co., 600 F.3d 465 (5th Cir. 2010) (evaluating plan administrator’s
failure
to
consider
an
SSA
decision
which
was
part
of
the
administrative record); Williams v. Hartford Life Ins. Co., 243 F.
App’x 795 (5th Cir. 2007) (refusing remand for reconsideration of
administrative
record);
Anderson
v.
Cytec
Indus.,
Inc.,
No.
07-5518, 2009 WL 911296 (E.D. La. Mar. 27, 2009), aff’d 619 F.3d
505 (5th Cir. 2010) (agreeing that there are “thorny timing issues”
with supplementation).
The plaintiff does not try to assert that the SSA decision is
properly part of the administrative record.
He also does not
assert that it relates to how the defendant interpreted the plan in
the past.
He does not claim admitting it would assist this Court
in understanding medical terms or procedures. The question here is
whether the SSA decision, one which was not before the defendant
until after this lawsuit was filed, can be added now.
The
plaintiff acknowledges that the SSA decision is not a part of the
record before the defendant and implores the Court to add it now.
It cannot be.1
The
plaintiff,
in
seeking
to
slip
the
SSA
decision
retroactively into the administrative record, effectively asks this
Court to resolve the merits of his benefits determination by
1
The plaintiff alternatively asks the Court to remand his
benefits claim for further fact-finding. This request comes too
late.
5
reviewing documents never before considered by the defendant. This
the Court has no authority in law to do.
The SSA decision was in
the possession of the plaintiff nearly a year before he sued the
defendant for denying him benefits.
At no point did the plaintiff
alert the decision to the defendant.2
Briefs on the remaining issues must be submitted not later
than August 8, 2011, as provided for in the pre-trial conference.
SO ORDERED.
New Orleans, Louisiana, August 1, 2011.
______________________________
MARTIN L. C. FELDMAN
UNITED STATES DISTRICT JUDGE
2
The question of whether the defendant should have been in
possession of the SSA decision without the plaintiff’s action is
not before this Court. See Vega, 188 F.3d at 298 (“There is no
justifiable basis for placing the burden solely on the
administrator to generate evidence relevant to deciding the
claim, which may or may not be available to it, or which may be
more readily available to the claimant.”). It is not the Court’s
role to speculate.
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