Thanks to Roy Harmon for blogging about a provocative new case from the federal District of Colorado, Hoyt v. The Prudential Ins. Co. of America, which you can read about on Health Plan Law here. I won't re-hash Roy's blog entry. But Hoyt serves as a reminder of the tension that exists between ERISA's limited scope of review and preserving the ability to evaluate the procedural integrity of an ERISA plan's decision-making.
Even though the Tenth Circuit, like almost all Circuits across the county, has provided fairly strict limits on introducing for the first time in litigation new evidence or reasons relating to the substance of the claim, those restrictions do not have the same force when dealing with information about the basic integrity of the process of evaluating and deciding a claim. I have no problem with being prevented from introducing a doctor's letter verifying that my client is disabled and that was available during the pre-litigation process but was not provided to the insurer. The letter's only relevance is whether the disabiility claim has merit--the substance of the claim. But discovery requested in litigation as to whether a plan's claim procedure process is full and fair, and thus complies with ERISA's procedural requirements, is another matter.
The distinction Hoyt makes between discovery directed to procedure versus substance does involve some challenges. The difference between discovery focused on substance and procedure is not always, or even usually, clear. The lines blur. Courts are wary of opening the door to discovery at all because it can become difficult to know where to draw the line on what discovery should be permitted and what should not. However, fairness suggests that courts should err on the side of allowing discovery, especially when a structural conflict of interest is in place, such as when a insurer is paying benefits.