In a recent decision
involving an ERISA claim for disability benefits, the Sixth Circuit held that, where a plan’s express definition of “objective findings” included “medication and/or treatment plan,” an administrator’s “additional requirement that the medication and treatment plan either cause the disability or confirm the applicant’s inability to work [found] no support in the plan’s terms.”
In that case, a Northeast Ohio factory worker suffered headaches that required medication as well as treatments such as an occipital nerve block. Although he sought disability benefits under his employer’s plan, the administrator denied benefits based solely on a lack of “objective findings.” Notably, the plan stated that “objective findings” included, besides diagnostic evidence (i.e. imaging studies and X-ray results), “medications and/or [a] treatment plan.”
In rejecting the medications and treatment plan identified by the claimant, the administrator interpreted the plan’s definition of “objective findings” as requiring that the medication’s side effects either cause the alleged disability or that the medication or treatment plan “objectively confirm” the claimant’s inability to work.
Although the Sixth Circuit noted that the administrator enjoyed “interpretive latitude” under the plan to determine benefit eligibility, the Court rejected the administrator’s interpretation as assigning an “additional requirement” not contemplated in the plan’s terms. Given that the plan administrator offered no other basis for denying the claim other than the lack of objective findings, and left the Court “guessing as to how [it] interpreted the plan’s objective-findings definition,” the Court found the administrative decision conclusory and unsupported by the plan, and remanded the case to the administrator for further review.