Issue: Whether evidence of a decedent’s platelet function is admissible in an action to review the denial of coverage
|Area of Law:||Employee Law, Healthcare & Pharmaceutical Law Compliance, Insurance Law|
|Keywords:||Admissibility of new evidence; Complicated medical issue; Platelet function|
|Cited Cases:||987 F.2d 1020; 144 F.3d 597|
Under ERISA, a court’s review of an insurer’s determination regarding coverage is normally limited to the information in the record at the time of an appeal of the insurer’s decision. Some courts have, however, made an exception to this rule and admitted evidence that was not before the insurer at the time of the appeal if the new evidence relates to a “complicated medical issue.”
While the exception for a complicated medical issue has been mentioned in many cases, only three cases were located in which the exception was successfully invoked to allow the admission of new evidence. In one of those cases, the ruling on the introduction of new evidence was reversed on rehearing en banc.
The leading case on the issue of the introduction of new evidence in a case involving de novo review of a decision of an ERISA plan is Quesinberry v. Life Ins. Co. of North America, 987 F.2d 1017 (4th Cir. 1993). In that case, the defendant Life Insurance Co. of North America (LINA) denied coverage under an accidental death insurance policy. The plaintiff claimed that his wife’s death was caused by a toxic reaction to an injection of Renografin she received during an emergency room visit. LINA claimed that the decedent’s sarcoidosis, in combination with the injection, “played a significant role in causing her death.” Quesinberry, 987 F.2d at 1020.FN1 The district court allowed the plaintiff to present “all admissible evidence, including evidence […]