The Ninth Circuit overturned the denial of benefits by a plan
administrator in a case that provides a useful "reverse
weathervane," showing several mistakes that a plan
administrator should not make when
reviewing a benefits claim. In Salomaa v. Honda Long Term
Disability Plan, No. 08-55426 (9th Cir. Mar. 7, 2011), the
Ninth Circuit held that plaintiff Samuel Salomaa met his burden of
showing that the Honda Long Term Disability Plan ("the
Plan") abused its discretion in denying his claim for
long-term disability benefits. Because the Plan made numerous
errors in denying Salomaa's claim for benefits and failed to
provide the "full and fair review" that ERISA requires,
the Ninth Circuit reversed the district court's affirmance of
the claim denial and remanded the case with instructions to award
disability benefits to the plaintiff.
Salomaa suffered from chronic fatigue syndrome, a condition
difficult to diagnose using objective medical tests. As stated by
Salomaa's treating physician, "usually there were no
physical findings for chronic fatigue syndrome except that the
patient looked fatigued." Despite having previously been a
model employee with no psychiatric history, Salomaa apparently was
unable to function normally on most days. Eliminating other
possible diagnoses, his doctors diagnosed chronic fatigue syndrome.
However, when Salomaa applied to the Plan for benefits, his initial
claim and claim appeal were denied.
Reviewing the record, the Ninth Circuit found many serious errors
in the Plan's claim review.
- The initial claim denial erroneously asserted that Salomaa had
no weight loss, when in fact he had lost 14% of his body weight
over a six month period. The final denial noted the weight loss but
then said there was "no underlying condition, such as cancer
or HIV disease", that might explain Salomaa's fatigue or
weight loss. The Ninth Circuit found such reasoning illogical,
since such objective measures are not used to establish the
existence of chronic fatigue syndrome.
- The initial claim denial misconstrued the process by which his
physicians attempted to diagnose and treat Salomaa's symptoms
of depression. The final denial did not even mention either
depression or lack of it as a basis for the decision to deny
benefits.
- The claims manager initially denied Salomaa's claim on the
basis that "Salomaa had no positive objective physical
findings" supporting his diagnosis, and invited him to
supplement the medical record. In response, Salomaa submitted a
supplemental report by his treating physician, documenting
significant functional limitations. Notwithstanding that new
report, the claims manager found an insufficient basis for the
claim.
- The Plan had Salomaa's record reviewed by two consulting
physicians, who said that Salomaa was not disabled. Neither of
their reports was provided to Salomaa's lawyer despite his
request for the Plan's file on the claim. Salomaa thus had no
opportunity to respond to those reports during the claim review
process.
- Every doctor who personally examined Salomaa found him to be
disabled. However, the Plan did not take advantage of Salomaa's
offer for the Plan's own consulting physicians to examine
him.
- Salomaa submitted evidence of his award of disability benefits from the Social Security Administration. That award was not binding on the Plan, but the Plan's claim denial did not even note, much less attempt to distinguish or refute, that award.
Significantly, the Plan's grounds for claim denial shifted as
Salomaa refuted each of the Plan's stated reasons. As Salomaa
developed and supplemented his medical records in support of his
claim, only the denial of the claim remained constant.
Based on these circumstances, the Ninth Circuit held that the
Plan's claims manager abused its discretion and did not provide
Salomaa a "full and fair" review of his claim as required
by ERISA.
The court also addressed the conflict of interest in Salomaa's
case in light of the Supreme Court's decisions in Metropolitan
Life Insurance Co. v. Glenn, 128 S. Ct. 2343 (2008), and
Conkright v. Frommert, 130 S. Ct. 1640 (2010). The Ninth
Circuit observed that, in applying those recent decisions,
"the administrator's decision cannot be disturbed if it is
reasonable," but a reversal would be appropriate where the
court is "left with a definite and firm conviction that a
mistake has been committed," and that "a higher degree of
skepticism is appropriate where the administrator has a conflict of
interest." The Ninth Circuit reached that conclusion in this
case, where the Plan's claim manager both administered the
claims process and paid the benefits, a conflict of interest. The
Ninth Circuit found that the repeated errors of the claims manager
did not provide Salomaa a full and fair review, and that increased
judicial skepticism was warranted.
Salomaa demonstrates that companies administering employee
benefit plans should carefully evaluate all of the evidence in the
claim record, acknowledge all evidence in denial letters, even if
such evidence is not thought to carry much weight, and be careful
to avoid factual errors that may provoke skepticism by a reviewing
court.
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