Medina v. Metro. Life Ins. Co
(1st. Cir. (P.R.) November 24, 2009)
The claimant's short-term disability benefits were terminated, and upon the claimant's appeal, sent out for independent review. After the reviewing physician's report was received, the administrator provided the report to the claimant's treating physician, and requested additional information. The claimant was on notice that such information was requested. The treating physician never responded. The administrator, based upon the independent evaluation, re-affirmed its denial of disability benefits. The claimant sued, asserting that the administrator was required to wait for the treating physician's feedback before denying benefits and its failure to do so was abuse of discretion. The court rejected that position, noting that the treating physician had numerous opportunities to respond, but remained silent. The court also held that because the administrator was not required to give particular weight to the treating physician's findings, there could be no obligation to wait for further input, holding that when the treating physician fails to respond to repeated requests for further data, the administrator is entitled to review the information available, so long as that information provides a sufficient basis to make a reasonable determination.
A copy of the decision can be located here
Sarah Delaney and Dan Gerber