Dallas Fort Worth Insurance Lawyer Blog
Employee Retirement Income Security Act (ERISA) cases have their own set of rules. Two things stand out about ERISA cases. One is that a person is not entitled to a jury trial in an ERISA case, rather a Judge reviews the administrative record in the case when deciding who is going to prevail in the case. Two is that there is very little to no discovery in the case.
This is illustrated in the 1998, 5th Circuit Court of Appeals opinion, Vega v. National Life Ins. Services, Inc.
Vega is a summary judgement case where Vega is appealing the decision rendered against hit. Part of his appeal addresses how the Court ruled as it relates to discovery in the case.
In this case, Vega had a health insurance plan governed by ERISA. At one point National Life refused to provide benefits for certain coverage. Vega properly requested an appeal of the administrator’s decision to deny benefits. National Life upheld the decision to not pay benefits on the administrative appeal. Vega then filed suit in the district court.
While the case was pending in the district court, Vega submitted affidavits from two experts who asserted that the decision National Life had made in denying benefits was wrong. The district court refused to consider the affidavits.
The district court reasoned that it could not consider the doctors’ affidavits submitted by Vegas because it could only consider evidence that was before the administrator at the time the administrator made its decision. This Court has ruled that a district court should only consider the evidence that was available to the plan administrator in evaluating whether the administrator abused its discretion in making a factual determination.
This Court has cautioned that a court must pause, before limiting itself to the record before the administrator, to assure itself that the administrator conducted a reasonable, good faith investigation of the claim.
In this case, this appeals Court specifically held that a district court should not consider expert testimony that was not before the plan administrator, absent certain conditions, which were not present in this case.