Group health and disability plans governed by ERISA have designated fiduciaries who oversee the plan’s administrative requirements. Fiduciaries are required by law to fully and fairly consider claims and to provide specific reasons for claim denials. Weaver v. Phoenix Home Life Mut. Ins. Co., 990 F.2d 154, 158 (4th Cir. 1993). In assessing claims, plan fiduciaries are required to act with an ‘”eye single” to the employee’s interests, and “cannot cherry-pick the best evidence in an employee’s file to support its desired conclusion.” Ramirez v. Liberty Life Assurance Co. of Bos., No. 3:18-CV-00012-RJC, 2019 WL 469930, at *10 (W.D.N.C. Feb. 6, 2019). They are also required to strictly follow ERISA regulations. If they do not, a court may impose a de novo standard of review even though an abuse of discretion review standard would have otherwise applied.

Under 29 C.F.R. Section 2560.503-1(i)(3)(i), a claim administrator has 45 days after a claimant files an appeal and this can only be extended for an additional 45 days in “special circumstances.” “If a claim administrator does not comply with the relevant deadlines, the claimant is deemed to have exhausted her administrative remedies and can file suit in federal court.” Rupprecht v. Reliance Standard Life Ins. Co., 623 F.Supp.3d 683, 691 (E.D. Va. 2022).

On April 10, 2024, in the matter of Wonsang v. Reliance Insurance Company, 2024 WL 1559292 (E.D. Virginia 2024), The court ruled in favor of Plaintiff Rebecca Wonsang (“Wonsang”), ruling that she was eligible to continue receiving long-term disability (“LTD”) benefits as well as for 26 months of back pay-benefits under a group disability policy governed by ERISA. The insurer, Reliance Standard Insurance Company (“Reliance”), had denied her claim for continued LTD benefits under its policy’s “any occupation” provision based upon its assertion that she had presented insufficient medical evidence to support her claim.

The court first had to address the standard of review. The court determined that by belatedly self-imposing a requirement for an IME, and thereby missing the 45-day deadline to decide Wonsang’s claim, it violated the applicable ERISA regulations. The court found that by missing this deadline, a de novo standard of review applied. The court then addressed the merits of Reliance’s “any occupation” denial. The court determined that Reliance simply failed to satisfy its fiduciary duty as mandated under ERISA to consider Wonsang’s claim fully and provide specific reasons for its denial of her claim. Wonsang stopped work due to alleged symptoms of arthralgia, back pain, neck pain from cervical herniated discs, fibromyalgia, chronic fatigue, Epstein Barre virus, IBS, and migraines. Id. at 2. Although she provided Reliance with substantial medical evidence from physicians who examined her symptoms, Reliance relied “almost exclusively on clinical staff members’ review[s] of Wonsang’s file rather than medical evidence by treating or examining providers,” and improperly denied her claim. Id. at 10.

The court rejected Reliance’s “minimalist approach in terms of its process for denying Wonsang’s benefits,” and ruled that Reliance improperly “emphasized isolated evidence to buttress its conclusions, while ignoring contradicting evidence,” when it denied Wonsang’s claim. Id. at 10-12. Reliance also attempted to argue that it was not obligated to accept a claimant’s subjective symptoms in assessing a claim. The court swiftly rejected this argument and reiterated that the law requires plan fiduciaries to not only consider claimants’ subjective symptoms but to consider their medication regimens as well in assessing benefit claims under ERISA. Id. at 12.

This decision highlights the importance of plan fiduciaries strictly following the time requirements of ERISA and making sure that they conduct a full and fair review of disability claims.