Jane Doe v. Harvard Pilgram, 2018 WL 4237288 (1st Cir.).

Jane Doe v. Harvard Pilgram, 2018 WL 4237288 (1st Cir.). Health benefits case in which participant was admitted to a mental health facility.  HPHC paid for the initial stay, then denied coverage for additional time.  Then she was readmitted and HPHC paid again.  Plaintiff sued after an unsuccessful appeal where she said the record was incomplete.  After suit was filed, HPHC told Plaintiff she had additional claims whose administrative remedies had not been exhausted.  The parties agreed to a post lawsuit review during which time Plaintiff submitted more evidence.  After HPHC denied that review HPHC filed an updated administrative record that did not include anything submitted after the final denial before suit was filed.  Plaintiff filed a motion to expand the record.  The district court denied it and found for HPHC.  Plaintiff appealed to the first circuit. 

            Plaintiff challenged the district court’s decision on the definition of the administrative record and the finding on the merits.  Regarding the record, the first circuit’s rule is that the decision for judicial review is the final administrative record and, absent a good reason or very good reason, courts reviewing that decision are limited to the evidence presented to the administrator as of that time.  Held that the administrative record for review includes documents submitted or generated as part of the post-filing review.  The court found that there was an unambiguous agreement to include this evidence in the record and found that in none of its cases had it suggested that an ERISA fiduciary can unilaterally walk away from a clear agreement with the beneficiary concerning the status of an administrative review under a plan.  The court had previously found that an administrative record can be reopened and the records supplemented.  Gross v. Sun Life Assurance Co. of Canada, 734 F.3d 1 (1st Cir. 2013).  Therefore there was a more than good reason to deem the documents submitted to HPHC after filing suit to be part of the record. 

            Regarding the review standard on the merits, the court held that where the court is reviewing the merits of an ERISA benefits denial de novo it will review the court’s factual findings for clear error.  They specifically offered no opinion on the standard of appellate review when the court below reviews a discretionary determination under the arbitrary and capricious standard.  See ft. 3.   They  cited a recent Supreme Court case, U.S. Bank National Ass’n ex rel. CWCapital Asset Management LLC v. Village at Lakeridge, LLC, -U.S.-, 138 S.Ct. 960, 200 L.Ed.2d 218 (2018).  They reasoned that summary judgment in the ERISA context is akin to judgment after a bench trial.