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The Long Term Disability Lawyer TOPIC: Unfair ERISA Claims Review Process Abram v. Cargill: Eighth Circuit Says Disability Claimant Must Have Full and Fair Review Abram v. Cargill was an important Eight Circuit case in which the Court rejected a claims review process as being unfair to the disability applicant. Ellen Abram was diagnosed in 1985 with Post Polio Syndrome (PPS), but she continued to work for Cargill Co. as a billing and accounting manager. Fifteen years later, her symptoms had deteriorated to the point that she had to apply for long term disability benefits. She submitted a report from her long-time doctor asserting that she was disabled by fatigue, weakness, and pain. Cargill’s Disability Plan sent Abram to an Independent Medical Examination conducted by Dr. Gedan. He concluded from his testing that Ms. Abram could continue to perform sedentary or “light duty” work, but suggested that a Functional Capacity Evaluation would shed more light on the situation. He also argued that obesity and depression were the main causes of Ms. Abram’s fatigue and pain, and not PPS, since she did not show the level of weakness that typically occurred in people suffering from PPS. Ms. Abram submitted a rebuttal from her doctor, but her claim was denied. During the period for appeal of her claim denial, Ms. Abram underwent a Functional Capacity Evaluation that simulated her workweek. The examining physician concluded that she could not perform full-time work and Ms. Abram separately documented that the position for which she was disabled was a 40-hour full-time position. At this stage the Disability Plan administrators took a number of steps that the Court found objectionable. They allowed the appeals deadline to pass without making a decision or informing Ms. Abram that they needed an extension. They sent her files back for further review by the Independent Medical Examiner Dr. Gedan, and after they received back his report supporting continued denial of the claim, they did not give Ms. Abram an opportunity to refute his conclusions and findings. They simply supplied her with a copy of his report along with their letter denying her appeal. In addition, the Court faulted the Disability Plan for not addressing the medical debate as to whether Ms. Abram’s symptoms were a result of PPS, obesity, or a combination. The Court believed this inquiry was critical to determining her eligibility for benefits. The Abrams Court offers an illuminating discussion of what constitutes a “full and fair review” of an ERISA disability claim. The opinion stated, ERISA and its accompanying regulations essentially call for a “meaningful dialogue between the plan administrators and their beneficiaries.” …Plan procedures cannot be “full and fair” without providing for this communication. It further cited a 1983 decision, “[T]he persistent core requirements” of full and fair review include “knowing what evidence the decision-maker relied upon, having an opportunity to address the accuracy and reliability of that evidence, and having the decision-maker consider the evidence presented by both parties prior to reaching and rendering his decision.” Grossmuller v. Int'l Union, UAW, 715 F.2d 853, 858 n.5 (3rd Cir. 1983).
When a
Disability Plan does not provide a meaningful opportunity for
the presentation of evidence and the rebuttal of that evidence
by both sides, then the door is opened to a charge that its
claims review process has been “arbitrary and capricious.” |
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Long Term Disability Attorney 2005