Case Review Corner: The Perils of Non-Cooperation in an ERISA Disability Claim

For Heaven’s sake: cooperate.

Whatever brought you here, I hope we can make a difference.

Welcome back to "Case Review Corner" here at Dorian Insurance Law PC. In this edition, we'll be examining the case of Holli Brynne Routten, as administrator of the estate of Kelly Routten, v. Life Insurance Company of North America, Case No. 5:22-CV-467-FL, decided on March 13, 2025, by Judge Louise W. Flanagan in the United States District Court for the Eastern District of North Carolina. This case serves as a stark reminder of the importance of full cooperation with the insurance company during the claim process, especially in the context of potential pre-existing conditions under ERISA.

The Case of Kelly Routten vs. LINA

The plaintiff, Kelly Routten, was an employee of FMR LLC and was covered under a long-term disability benefit plan sponsored by her employer and funded by a group policy issued by Life Insurance Company of North America ("LINA"). Ms. Routten stopped working for FMR LLC on November 24, 2020, due to multiple sclerosis.

She initially received short-term disability benefits administered by LINA, which did not have a pre-existing condition clause. However, when Ms. Routten's claim was evaluated for a transition to long-term disability benefits, LINA raised concerns about the plan's pre-existing condition limitation. This limitation stated that benefits would not be paid for a disability caused or contributed to by a condition for which the employee received medical treatment, care, or took prescribed drugs within three months before her coverage effective date of March 2, 2020.

During their investigation, LINA discovered through pharmacy records that Ms. Routten had filled prescriptions for Gilenya, a multiple sclerosis medication, several times between December 2019 and February 2020, prior to her coverage effective date. Ms. Routten disputed these records, claiming they were due to pharmacy errors.

Ms. Routten had a call with a LINA nurse case manager where she stated she had been diagnosed with multiple sclerosis in 2009 and had been seeing a physician, "Dr. Skeen," regularly for the condition.

LINA requested medical records from Dr. Skeen. Initially, Ms. Routten provided an authorization. Based on records received from Duke Health for a January 16, 2020, office visit confirming treatment for multiple sclerosis, LINA denied Ms. Routten's long-term disability claim, citing the pre-existing condition provision.

Ms. Routten appealed, arguing the provision didn't apply because she was employed during the relevant period and claimed she had provided documentation showing no treatment for three months. LINA had a neurologist review her file, who concluded her disabling multiple sclerosis was the same condition treated during the pre-existing lookback period. However, the neurologist noted a lack of records for a significant period.

LINA requested further records from Dr. Skeen. In response, Ms. Routten sent a fax stating, "I REVOKE ALL PRIOR AUTHORIZATIONS TO RELEASE MY MEDICAL INFORMATION Due to an abuse of plan specifications."

Subsequently, LINA upheld its denial, citing both the pre-existing condition provision and the plan's claimant cooperation provision, which stated that failure to cooperate by providing necessary information could result in termination of the claim.

The Legal Issue: Abuse of Discretion and the Duty to Cooperate under ERISA

In this case, the benefit plan granted LINA discretionary authority to interpret the plan and determine eligibility. Therefore, the court reviewed LINA's denial of benefits under the "abuse of discretion" standard. This is a deferential standard, meaning the court will uphold the administrator's decision if it was reasonable.

Judge Flanagan focused significantly on the plan's claimant cooperation provision. The court found that the plan language clearly required Ms. Routten to provide requested information and that her revocation of the medical records authorization constituted a failure to cooperate.

The Court's Findings:

The court granted LINA's motion for summary judgment, effectively upholding the denial of benefits. Judge Flanagan reasoned that LINA's decision to deny benefits based on Ms. Routten's failure to cooperate was reasonable under the abuse of discretion standard.

The court noted that the plan language unambiguously warned Ms. Routten about the consequences of not providing requested documentation. Even if there were questions about the pre-existing condition, Ms. Routten's refusal to allow LINA to obtain the necessary medical records for a critical period provided an independent and reasonable basis for the denial under the plan's cooperation provision.

Judge Flanagan reviewed the eight factors outlined in Booth v. Wal-Mart Stores, Inc. Associates Health & Welfare Plan to assess the reasonableness of LINA's decision. The court found that all eight factors either supported LINA's decision or were inapplicable.

What Ms. Routten Did Correctly (Initially):

• Applied for Benefits: Ms. Routten took the initial step to apply for both short-term and long-term disability benefits.

• Initially Provided Some Information: She initially provided some medical information and participated in a call with the nurse case manager.

What Ms. Routten Could Have Done Better (and Lessons for Claimants):

• Maintain Consistent Communication and Cooperation: This case highlights the paramount importance of cooperating fully with the insurance company's requests for information and documentation. Revoking authorization for medical records, especially when there are questions about a pre-existing condition, can have severe consequences for your claim.

• Address Discrepancies in Medical History Proactively: If there are potential discrepancies in your medical records, such as the pharmacy records in this case, it's crucial to address them proactively and provide clear explanations and supporting documentation to the insurance company.

• Understand the Terms of Your Policy: Familiarize yourself with all the terms of your disability insurance policy, including pre-existing condition clauses and cooperation requirements.

• Seek Legal Counsel Early: Consulting with an experienced ERISA attorney like those at Dorian Law PC early in the claims process can help you understand your obligations, navigate complex issues like pre-existing conditions, and ensure you are properly cooperating with the insurance company to avoid a denial.

For Legal Professionals: The Interplay of the Cooperation Clause and Abuse of Discretion Review Under ERISA

The Routten v. LINA decision hinges significantly on the application of the abuse of discretion standard of review, a consequence of the plan granting discretionary authority to LINA. The court explicitly cites Johnson v. Am. United Life Ins. Co., 716 F.3d 813, 819 (4th Cir. 2013), for the principle that this discretionary authority dictates the standard of review.  

Furthermore, the court's analysis relies heavily on the plan's claimant cooperation provision, referencing its unambiguous language allowing for claim termination due to a failure to cooperate. In evaluating the reasonableness of LINA's decision, Judge Flanagan applies the eight factors articulated in Booth v. Wal-Mart Stores, Inc. Associates Health & Welfare Plan, 201 F.3d 335, 341-42 (4th Cir. 2000). Notably, the court finds that LINA's denial was reasonable, even if the pre-existing condition argument was debatable, because Ms. Routten's revocation of medical authorizations directly violated the cooperation clause. The court also cites cases like Miller v. Metropolitan Life Ins. Co., 925 F.2d 979, 986 (6th Cir. 1991), and Taylor v. Broadspire Servicing, Inc., 314 Fed.Appx. 187, 193 (11th Cir. 2008), which affirmed benefit denials based on a claimant's refusal to cooperate.  

The Lesson: This case reinforces the critical importance of advising clients in ERISA disability benefit matters about the binding nature of claimant cooperation provisions, especially when the plan is subject to abuse of discretion review. While advocating on the merits of the disability claim, practitioners must emphasize that a failure to cooperate with reasonable requests for information can provide an independent and defensible basis for the insurer's denial under the deferential standard. Even under the Booth factors, a clear violation of the plan's terms, such as the cooperation clause, will likely be upheld by the court.

Conclusion:

The case of Kelly Routten v. LINA underscores that while the validity of a pre-existing condition exclusion can be a complex legal issue, a claimant's failure to cooperate with the insurance company can provide an independent and sufficient reason for a denial of benefits under an ERISA plan. This case serves as a critical lesson for claimants in North Carolina and nationwide: full and open cooperation throughout the claim process is essential to protect your right to disability benefits.

Were you asked to provide medical information for your disability claim and are unsure about your obligations? The Routten case highlights the critical importance of cooperation with your insurance company. At Dorian Law PC, we can guide you through the information-gathering process and ensure you understand your rights and responsibilities under your ERISA disability policy. Contact us today for a confidential consultation.

Disclaimer: The information provided here is for general knowledge and informational purposes only, and does not constitute legal advice. You should consult with a qualified lawyer for advice regarding your specific situation.