Seyfarth Synopsis: A recent 10th Circuit decision holding that in order for the abuse of discretion standard to apply in litigation the claims administrator must provide participants with actual notice of discretionary authority or notice of a document affecting standard of review is required, signals a departure from the existing ERISA legal landscape.
In ERISA benefit claim litigation, where there is a sufficient delegation of discretionary authority to an administrator in the governing plan document, a court reviewing an administrator's decision will generally employ the highly deferential abuse of discretion standard of judicial review rather than the de novo standard of review.
In a recent mental health treatment case, the Tenth Circuit added additional requirements before a court will apply the abuse of discretion standard to analyze a benefit claim determination. Lyn M.; David M., as Legal Guardians of L.M., a minor v. Premera Blue Cross, No. 18-4098, __ F.3d __. The court ruled that despite a grant of discretion to the administrator in the governing plan document, the deferential standard of review could not apply in litigation as there was no evidence demonstrating plan participants knew that the employer's plan document containing the discretionary authority clause existed. Rather, the participants had received only an SPD, which was silent as to discretionary authority. The Court determined that proper notice requires the plan administrator to either (1) actually disclose its discretionary authority or (2) explicitly disclose the existence of the plan document containing information about the discretionary authority. The court found that the fact that the governing plan document was available to participants on request was insufficient this new disclosure requirement.
In a biting dissent, Judge Allison H. Eid reasoned that the SPD sufficiently alerted participants that other plan documents existed and were available. Judge Eid criticized the majority for imposing a duty on plan administrators, found nowhere in ERISA or case law, "to specifically inform members that documents exist that could affect judicial review." The dissent correctly noted that while SPDs must be provided and include certain mandatory information regarding benefit eligibility and claim procedures, there is no duty under ERISA to specifically notify participants of documents that may affect the judicial standard of review should their claims be decided in court.
This decision is a significant departure from the standard principle that the standard of review employed by a reviewing court does not turn on whether the document containing that standard was provided to participants during the claim review process. Only time will tell if other courts will adopt the Tenth Circuit's position. For now, benefit plans operating in the Tenth Circuit should evaluate their claim procedures in light of this decision.
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