District Court Orders Inclusion of External Medical Review Documents in ERISA Administrative Record

In Noelle E. v. Cigna Health & Life Ins. Co., 2:23-cv-00686, 2025 WL 754031 (D. Utah Mar. 10, 2025), in a medical benefits action brought under the Employee Retirement Income Security Act of 1974 (“ERISA”), Utah District Judge Howard C. Nielson Jr. granted Plaintiffs’ motion to complete the administrative record with materials related to an external review process that Cigna omitted from disclosure during litigation.

This case arose from Cigna’s denial of insurance coverage for medical care received by minor child H.E., prompting H.E. and his mother, Noelle E., to bring an action against Cigna under ERISA. After Cigna upheld its denial through its internal appeal process, Plaintiffs sought an external review, as allowed by the insurance plan. In this external review, Plaintiffs submitted an appeal letter and several exhibits, which Cigna did not review or include in the administrative record produced in the subsequent litigation.

Plaintiffs filed a motion to complete the administrative record by including these documents. Cigna opposed the motion, arguing that the documents should not be part of the record since they were neither reviewed nor considered during Cigna’s internal decision-making process. However, the external reviewer partially overturned Cigna’s denial, and the external review was binding under the terms of the plan.

The court’s analysis focused on the scope of the administrative record under ERISA. ERISA regulations state that the administrative record should include all documents “submitted, considered, or generated in the course of making the benefit determination,” regardless of whether they were relied upon in making the decision. 29 C.F.R. § 2560.503-1(m)(8). The court rejected Cigna’s argument that documents must be reviewed by the plan administrator to be included in the record.

The court emphasized that the documents submitted during the external review process are indeed relevant to the administrative record. This aligns with ERISA’s requirement for completeness and transparency in the claims process, ensuring that all pertinent information is available for judicial review. The court noted that the external reviewer’s decision, which was binding on Cigna, inherently informed Cigna’s ultimate decision on the benefits claim.

The court drew parallels with the Eleventh Circuit’s decision in Alexandra H. v. Oxford Health Insurance Inc., 833 F.3d 1299 (11th Cir. 2016), where the external review was deemed part of the administrative record because it was binding on the insurer and informed the final decision. This precedent supports the inclusion of external review documents to ensure fairness and to reflect the reality of the decision-making process under the terms of the plan.

The court granted Plaintiffs’ motion to complete the administrative record, thereby requiring Cigna to include the appeal letter and exhibits submitted during the external review, reinforcing the principle that ERISA plan administrators must ensure the administrative record is comprehensive, encompassing all relevant materials generated throughout the claims process. The ruling highlights the judicial system’s role in maintaining transparency and fairness in ERISA disputes, ensuring that all information impacting the decision is available for review.

If your Plan or Plan Administrator has denied or otherwise limited your ERISA benefits claim, contact us for assistance.