Sansby v. Prudential Insurance Company of America

Full title: SUSAN SANSBY v. PRUDENTIAL INSURANCE COMPANY OF AMERICA and HARVARD…

Court: United States District Court, D. Massachusetts

Date published: Mar 25, 2009

CIVIL ACTION NO. 07-11524-RGS (D. Mass. Mar. 25, 2009)

Opinion

CIVIL ACTION NO. 07-11524-RGS.

March 25, 2009

MEMORANDUM AND ORDER ON PLAINTIFF'S MOTION FOR DISCOVERY AND TO EXPAND THE SCOPE OF THE RECORD

RICHARD STEARNS, District Judge

Plaintiff Susan Sansby was employed by Harvard Pilgrim Health Care in May of 2004, when she suffered severe pain in her lower back, upper hips, and thighs. Sansby has undergone two surgeries to alleviate her pain. Despite Sansby's medical history, on August 16, 2004, Prudential Insurance Company of America (Prudential) denied Sansby's application for long-term disability benefits. After three unsuccessful internal appeals, Sansby brought this action in the district court under the Employee Retirement Income Security Act (ERISA), 29 U.S.C. § 1001 et seq., challenging Prudential's denial. Sansby now seeks limited pre-trial discovery to supplement the administrative record. Prudential opposes the motion.

DISCUSSION

Sansby seeks to discover two categories of information. First, she seeks the claims manuals and instructional materials that were relied on by Prudential's claims adjusters in processing her claims. Next, she seeks to discover information regarding Prudential's relationships with MLS National Medical Evaluation Services, Inc. (MLS), and Dr. Patrick Foye. Prudential relied almost exclusively on the opinions of two MLS physicians and Dr. Foye in denying Sansby's claim.

In an ERISA appeal, the supplementation of the Administrative Record is not a matter of right. Lopes v. Metro. Life Ins. Co., 332 F.3d 1, 5 (1st Cir. 2003). Rather, the First Circuit cautions that "some very good reason is needed to overcome the strong presumption that the record on review is limited to the record before the administrator." Liston v. Unum Corp. Officer Severance Plan, 330 F.3d 19, 23 (1st Cir. 2003).

1. Claims Manuals

Both Congress and the United States Department of Labor (DOL) require plan administrators to disclose to claimants the materials relied upon by the administrator in evaluating a claim.See, e.g., 29 U.S.C. § 1132(c) (plan administrators required to disclose documents within thirty (30) days of receiving a written request).

[U]nder new federal regulations, claimants are entitled to obtain copies of precisely such documents. ERISA requires that "[i]n accordance with regulations of the Secretary [of Labor]," every employee benefit plan must provide participants whose benefits claims were denied with a "full and fair review" of the denial. 29 U.S.C. § 1133 (2003). In 2000, the Department of Labor promulgated regulations interpreting "full and fair review" to require that claimants be given access to all "relevant" documents. 29 C.F.R. § 2560.503-1(h)(2)(iii).

Where the plan in question provides disability benefits, the Department of Labor defines "relevant" documents to include "statement[s] of policy or guidance with respect to the plan concerning the denied treatment option or benefit for the claimant's diagnosis, without regard to whether such advice or statement was relied upon in making the benefit determination." § 2560.503-1(m)(8)(iv). The Department indicated that these new regulations were intended to make clear that "the claimant should receive any information demonstrating that, in making the adverse benefit determination, the plan complied with its own processes for ensuring appropriate decisionmaking and consistency." 65 Fed.Reg. 70,246, 70,252 (Nov. 21, 2000).

Glista v. Unum Life Ins. Co. of Am., 378 F.3d 113, 123 (1st Cir. 2004). Glista makes crystal clear Sansby's entitlement to the claims manuals and training guides. Accordingly, her motion isALLOWED with respect to Document Request Number 1. There is, however, no discernible justification for the requested deposition of Joseph Walles, one of Prudential's claims adjusters. That request is therefore DENIED.

2. Physician Relationships

Sansby next argues that she is entitled to additional discovery in light of the Supreme Court's recent holding in Metro. Life Ins. Co. v. Glenn, 128 S.Ct. 2343 (2008). In Glenn, the Court announced that a conflict of interest exists whenever, as here, a "plan administrator both evaluates claims for benefits and pays benefits claims." Id. at 2348. The Court instructed district courts to "take account of [the conflict of interest] as a factor in determining the ultimate adequacy of the record's support for the agency's own factual conclusion." Id. at 2352.

This court recently ruled that Glenn does not justify automatic discovery on the mere allegation of a conflict of interest. See McGahey v. Harvard Univ. Flexible Benefits Plan, C.A. No. 08-10435-RGS, slip op. at 4 (Mar. 25, 2009). Rather, the court will permit discovery only where a plaintiff makes a satisfactory threshold showing that the administrator's conflict of interest influenced the denial of benefits. Id. at 4-5. Here, Sansby claims that she presented extensive medical and vocational evidence in support of her claim. Included in Sansby's file were numerous medical reports — from surgeons, internists, pain management doctors, psychiatrists, rheumatologists, neurologists, and an inpatient pain management program — all supportive of her claim of disability. In addition, Sansby submitted to independent medical examinations as requested by the Department of Industrial Accidents and the claims administrator, as well as to two independent vocational examinations. Prudential, however, based its denial of benefits solely on the opinions of the two MLS physicians and Dr. Foye, none of whom personally examined Sansby. Prudential's denial of benefits in the face of what appears to be overwhelming evidence supporting Sansby's claim satisfies her burden of a making of a preliminary showing that a conflict of interest may have influenced Prudential's decision.

Accordingly, Sansby is entitled to the production of all documents that reflect correspondence between Prudential, MLS, and Dr. Foye, with regard to her claim. In addition, Sansby is entitled to the production of documents shedding light on Prudential's relationship with MLS and Dr. Foye during the four-year period during which Sansby's claim was being processed, including any instructions given by Prudential to MLS and Dr. Foye regarding the writing of reports; the total amount of compensation paid to MLS and Dr. Foye during the four-year period; the number of claims referred by Prudential to MLS and to Dr. Foye; and reliable statistics showing the number of claims that MLS and Dr. Foye recommended be denied, as opposed to the number of claims that MLS and Dr. Foye recommended be allowed.

ORDER

For the foregoing reasons, Sansby's motion for discovery isALLOWED in part, consistent with the instructions in this Order. Sansby is to serve her discovery requests within fourteen (14) days of the date of this Order. Prudential shall comply with the requests within thirty (30) days thereafter.

SO ORDERED.