Physician’s Involvement in Denial and Review on Appeal Consistent with ERISA
An employee challenged the decision of her disability insurer, AT & T Umbrella Benefit Plan No. 3, to terminate her short-term disability benefits. The Plan gave discretion to its third party claims administrator (“TPA”) to decide whether an employee had a qualifying disability under the Plan. The employee challenged the TPA’s decision to allow the doctor who originally denied her benefits to participate in the consideration of her appeal. ERISA expressly requires on appeal that the plan consult an individual who was not consulted in the decision to deny benefits. The Sixth Circuit found the TPA consulted two other physicians so the decision to have the original doctor review the employee's documents on appeal did not deprive her of a full and fair review of the adverse benefit determination.