United Behavioral Health, et al. v. D. K., et al.

The Employee Retirement Income Security Act of 1974 (ERISA) requires plans to provide members written notice of the reasons for a benefits denial in understandable terms. In Black & Decker Disability Plan v. Nord, 538 U.S. 822, 831–34 (2003), this Court held that courts may not require plans denying benefits to also explain why they disagree with the member’s treating physicians. The Court noted, however, that the Department of Labor (“DOL”) could potentially undertake rulemaking to add that requirement. Id. at 831. Thirteen years later, DOL revised its disability benefits regulations to require a discussion of treating provider opinions. But DOL has never similarly amended its health benefits regulations. In the decision below, the Tenth Circuit nevertheless imposed on health benefits plans the same treating provider requirement rejected in Nord—even though DOL has not adopted that requirement by regulation. That holding conflicts with the approach of five other Circuits and many district courts, threatening the uniformity ERISA was designed to ensure. The Tenth Circuit also changed judicial review of benefits decisions in another way. It refused to review the whole administrative record to determine if the decision is supported by substantial evidence, holding that courts must focus on the decision letters and disregard other record evidence—even when a plan relies on such evidence simply to rebut arguments raised during the appeals process. This narrow view of the scope of review for benefits decisions is a clear break from the precedent of most circuits. And it undermines Congress’s intent that benefits decisions be simply explained in understandable terms.