The United States District Court for the Northern District of Indiana recently examined the issue of determining what constitutes the administrative record where an insurance company fails to meet regulatory deadlines under the Employee Retirement Income Security Act of 1974 (ERISA).  Essentially, this meant that the Court had to decide whether Reliance Standard would be able to introduce evidence before the Court that was gathered after the expiration of the time period to make a decision on the long-term disability (LTD) claim at issue.

In King v. Reliance Standard Life Insurance Company, 2024 WL 5165572 (N.D. Ind. Dec. 19, 2024) the Court decided the issue of whether defendant Reliance Standard Life insurance Company (Reliance Standard) improperly denied plaintiff Megan King’s LTD claim. The case centered around Reliance Standard’s failure to render a decision on her claim within the 45-day requirement of the Department of Labor’s (DOL) ERISA claims regulations.

King became disabled in 2018 and Reliance Standard approved her LTD claim and paid her benefits for four years. In September 2022 Reliance Standard determined King was no longer disabled and notified her that her benefits would be discontinued. King appealed in July 2023. As of September 11, 2023 King had not received a decision from Reliance Standard, nor had Reliance Standard invoked a need for additional time to review her appeal. The DOL regulations require insurance companies to provide a response within 45 days and allow them to take an additional 30 days when they are unable to complete the review due to something outside their control, though they must notify the claimant of the need for this extra time before the 45-day period runs. When King did not receive either a decision or notice of a need for additional time within 45 days, she considered her administrative remedies exhausted and filed a federal lawsuit under ERISA. Reliance Standard denied King’s appeal four months later.

The issue before the court focused on whether evidence gathered by Reliance Standard after the exhaustion deadline could be included in the court’s review. King argued that the administrative record should close once the regulatory deadlines expired, emphasizing ERISA’s strict procedural safeguards. The court agreed, granting King’s motion to exclude post-exhaustion evidence from the record. The court held that once a claim is deemed exhausted, the plan administrator cannot introduce additional evidence to justify its denial.

The court cited Fessenden v. Reliance Standard Life Ins. Co., 927 F.3d 998 (7th Cir. 2019) and determined that because Reliance Standard violated its obligations mandated by the DOL regulations, its late decision is not entitled to the deference provided by the abuse of discretion standard of review. The court therefore determined that the standard of review was de novo. The court further cited Dorris v. Unum Life Ins. Co. of America, 949 F.3d 297 (7th Cir. 2020), noting that the court can limit itself to deciding the case on the administrative record but should also freely allow the parties to introduce relevant extra-record evidence and seek appropriate discovery. The court thus found that the scope of the record is within its discretion.

On this basis, the court found in King’s favor and against Reliance Standard, reasoning that affording Reliance Standard extra time to gather evidence would undercut the benefits of King having exhausted her administrative remedies. The court concluded that Reliance Standard relinquished its opportunity to establish its evidence in the administrative record and that to allow Reliance Standard to submit its evidence after already missing the deadline would circumvent the purpose of the DOL regulation.

The court focused on the evidence Reliance Standard wanted to include in the administrative record and held that if the court allowed the inclusion of post-exhaustion evidence that creates a party’s administrative record rather than supplements it, the court would be impermissibly extending the DOL deadlines.

The King decision demonstrates the importance of understanding ERISA’s complex regulations governing employee benefits such as disability claims and the importance of utilizing the regulations to maximize a successful outcome. McKennon Law Group PC has similarly used this specific ERISA regulation to achieve success in handling its clients disability claims. Having the right ERISA disability insurance lawyer can make the difference between success and failure.