You know that in ERISA claims where the court is applying the abuse of discretion standard, the court may allow “conflict discovery.” This might include discovery of claims manuals, for example.

But even if the court allows conflict discovery, the court likely may still prohibit Plaintiff from supplementing the administrative record with this discovery.

Here’s the case of Prohkorova v. Unum Life Ins. Co. of Am., 2018 WL 1913801 (D. Mass., April 23, 2018) (Plaintiff’s request to supplement the administrative record (with conflict discovery) rejected because Plaintiff “failed to identify a ‘serious claim of …procedural misconduct’ … that would ‘overcome the strong presumption’ [against supplementing the record]”).

This new case outlines arguments one can use to oppose Plaintiff’s moves to supplement the administrative record with “conflict discovery.”

FACTS: Plaintiff, a pediatrician, sought ERISA-governed disability benefits due to a disc herniation. Unum denied the claim because an MRI failed to show clinically significant nerve root impingement, and reviews confirmed there was no psychiatric cause of self-reported pain symptoms. The Court applied discretionary review, and allowed discovery into whether a structural conflict “morphed into an actual conflict.”

Plaintiff then sought to supplement the record with the conflict discovery the Court had allowed, including the Unum Claims Manual produced in discovery.

ISSUE: Whether the Court should allow supplementation of the administrative record to include the claims manual.

DISTRICT COURT HELD: Most conflict discovery obtained was NOT allowed to supplement the administrative record:

  1. Conflict discovery should be allowed only where there is a “serious claim of bias or procedural misconduct toward [the claimant]… [and there exists] ‘at least some very good reason…to overcome the strong presumption that the record on review is limited to the record before the administrator.’” Op. at 4.
  2. The issue for this court is whether Plaintiff has “shown some very good reason in the context of this case to overcome the strong presumption against supplementing the record….” Op. at 5.
  3. The Court rejected Plaintiff’s request to supplement the record with portions of Unum’s Claims Manual addressing procedures Unum uses to assess the claimant’s ability to perform her own occupation. Op. at 7-8. Unum’s vocational rehabilitation consultant properly relied upon the Dictionary of Occupational Titles. Plaintiff “failed to identify a ‘serious claim of …procedural misconduct’ in connection with Unum’s vocational assessment that would ‘overcome the strong presumption’ [against supplementing the record].” Op. at 7-8.
  4. The Court rejected Plaintiff’s request to supplement the record with requirements in Unum’s Claims Manual regarding how reviews by non-examining physicians employed by Unum must be performed. The manual required the Unum-employed physician to apply “critical scientific analysis.” The Court refused to supplement the record with this part of the Claims Manual because “[j]udicial review…should not be focused on the interpretation of a nonspecific provision in the Claims Manual.” Op. at 8.
  5. The Court rejected Plaintiff’s request to supplement the record with requirements in Unum’s Claims Manual that Unum “giv[e] deference to the opinion of the claimant’s [attending physician(s)].” The Court excluded this from the record because that portion of the Unum’s Claims Manual is “‘contrary to binding precedent.’” Op. at 9 (citing Black & Decker v. Nord, 538 U.S. 822, 831 (2003).
  6. The Court allowed Plaintiff’s request to supplement the record with portions of Unum’s Claims Manual which addressed the process Unum is supposed to use to assess claims based on subjective complaints of pain. Op. at 10.
  7. The Court rejected Plaintiff’s request to discover Unum’s Quality Compliance Criteria because there is no evidence the criteria was was “relied on in making the benefit determination[]” or that the criteria was required to ensure a full and fair review. Op. at 11.
  8. The Court rejected Plaintiff’s request to supplement the record with new vocational resource material because this new material could have been submitted before the adverse benefit determination. Op. at 13.