Abatie v. Alta Health & Life Ins. Co. (2006)

Id. at 970 (“Today, we continue to recognize that, in general, a district court may review only the administrative record when considering whether the plan administrator abused its discretion, but may admit additional evidence on de novo review.”).

In fact, Abatie “consciously] rejected]” the “sliding scale metaphor” that some other circuits had adopted, which involved adjusting the level of “deference” or “scrutiny” in the standard of review itself in proportion to the “seriousness of the conflict.” Id. at 967 (internal quotation marks omitted); see also id. at 968 (“[I]n any given case, all the facts and circumstances must be considered, and nothing ‘slides[.]’ ”).

In fact, Abatie "conscious[ly] reject[ed]" the "sliding scale metaphor" that some other circuits had adopted, which involved adjusting the level of "deference" or "scrutiny" in the standard of review itself in proportion to the "seriousness of the conflict." Id. at 967 (internal quotation marks omitted); see also id. at 968 ("[I]n any given case, all the facts and circumstances must be considered, and nothing "slides[.]'").

See Abatie, 458 F.3d at 963 (“[I]f the plan does confer discretionary authority as a matter of contractual agreement, then the standard of review shifts to abuse of discretion.”) (citation omitted) (emphasis in original).

Cf. id. at 972 (“[W]hen a plan administrator’s actions fall so far outside the strictures of ERISA that it can- not be said that the administrator exercised the discretion that ERISA and the ERISA plan grant, no deference is warrant- ed.”).

Cf. id. at 972 (“[W]hen a plan administrator’s actions fall so far outside the strictures of ERISA that it cannot be said that the administrator exercised the discretion that ERISA and the ERISA plan grant, no deference is warranted.”).

Cf. id. at 972 (“[W]hen a plan administrator’s actions fall so far outside the strictures of ERISA that it cannot be said that the administrator exercised the discretion that ERISA and the ERISA plan grant, no deference is warranted.”).

See id. at 973 ("[I]f the plan administrator's procedural defalcations are flagrant, de novo review applies."); see also Amato, 618 F.2d at 568 ("[P]rior fully considered actions by pension plan trustees interpreting their plans. . . may well assist the courts when they are called upon to resolve the controversies." (Emphasis added.)).

Abatie, 458 F.3d at 968 (“weighing a conflict of interest as a factor in abuse of discretion review requires a case-by-case balance”).

Moreover, the district court should consider evidence outside the administrative record to “recreate what the administrative record would have been had the procedure been correct.” Id. at 973 (“[T]he court may take additional evidence when the irregularities have prevented full development of the administrative record.”).

See Abatie, 458 F.3d at 963 (“[I]f the plan does confer discretionary authority as a matter of contractual agreement, then the standard of review shifts to abuse of discretion.”) (citation omitted) (emphasis in original).

Co., 458 F.3d 955, 962 (9th Cir.2006) (en banc). 4 See also Abatie, 458 F.3d at 967 ("We read Firestone to require abuse of discretion review whenever an ERISA plan grants discretion to the plan administrator, but a review informed by the nature, extent, and effect on the decision-making process of any conflict of interest that may appear in the record."). 5 ERISA defines an "employee pension benefit plan" as "any plan, fund, or program which was heretofore or is hereafter e…

Airlines Pension Plan for Contract Emps., 484 F.3d 1211, 1216 (9th Cir. 2007) (setting forth standard of review for a district court’s decision to admit or exclude evidence that was not before the plan administrator); Abatie, 458 F.3d at 970 (“[I]n general, a district court may review only the administrative record when considering whether the plan administrator abused its discretion.... ”); Mahon v. Credit Bureau of Placer Cty., Inc., 171 F.3d 1197 , 1200 (9th Cir. 1999) (s…

See id. at 968-69 (“The level of skepticism with which [we view] a conflicted administrator’s decision may be low if a structural conflict of interest is unaccompanied, for example, by any evidence of malice, of self-dealing, or of a parsimonious elaims-grant-ing history.”).

See Abatie, 458 F.3d at 970 (“[I]n general, a district court may review only the administrative record when considering whether the plan administrator abused its discretion!;.]”).

See Abatie, 458 F.3d at 970 (“[I]n general, a district court may review only the administrative record when considering whether the plan administrator abused its discretion!;.]”).

See id. at 973 (“[I]f the plan administrator’s procedural defalcations are flagrant, de novo review applies.”); see also Amato, 618 F.2d at 568 (“[P]rior fully con- sidered actions by pension plan trustees interpreting their plans . . . may well assist the courts when they are called upon to resolve the controversies.” (Emphasis added.)).

Co., 458 F.3d 955, 962 (9th Cir. 2006) (en banc) (citation omitted).

Consistent with Ninth Circuit authority, the Court finds that this provision unambiguously vests discretion in UNUM as the plan’s administrator. 4 Abatie, 458 F.3d at 963 (“[W]e have repeatedly held that similar plan wording—granting the power to interpret plan terms and to make final benefits determinations—confers discretion on the plan administrator.”) (citing Bergt v. Ret.

See Abatie, 458 F.3d at 973 (“[T]he court may take additional evidence when [procedural irregularities] have prevented full development of the administrative record.”). : Initials of Preparer DTA CENTRAL DISTRICT OF CALIFORNIA CIVIL MINUTES - GENERAL Case No. 2:24-cv-04612-SVW Date July 31, 2025 Title Emsurgcare et al. v. Oxford Health Insurance, Inc. iii.

Under the abuse of discretion standard, a court generally limits its review to the record before the plan administrator. 4 Id. at 970 (“Today, we continue to recognize that, in general, a district court may review only the administrative record when considering whether the plan administrator abused its discretion ... ”).

Co., 458 F.3d 955, 970 (9th Cir.2006). *883 Here, defendant essentially concedes that it serves in the dual role of claims fiduciary and funding source of the benefits, which creates the so-called “structural conflict of interest.” See Aba-tie, 458 F.3d at 965 (“We have held that an insurer that acts as both the plan administrator and the funding source for benefits operates under what may be termed a structural conflict of interest.”).

Id. (“We advised Metro West of your settlement offer ... and also communicated the findings of our internal medical director.

Glenn , 554 U.S. at 112 , 128 S.Ct. 2343 ; Abatie , 458 F.3d at 965 ("We have held that an insurer that acts as both the plan administrator and the funding source for benefits operates under what may be termed a structural conflict of interest").

Glenn, 128 S.Ct. 2343, 2348 (internal citations omitted); see also Abatie, 458 F.3d at 966 (“an inherent conflict of interest, even if merely formal and unaccompanied by indicia of bad faith or self-dealing, ought to have some effect on judicial review.”) 5.

Gatti, 415 F.3d at 985 ; see also Abatie, 458 F.3d at 971 (“[I]f the plan administrator’s procedural defalcations are flagrant, de novo review applies.”).

See Abatie, 458 F.3d at 968 (“The level of skepticism with which a court views a conflicted administrator’s decision may be low if a structural conflict of interest is unaccompanied, for example, by any evidence of malice, of self-dealing, or of a parsimonious claims-granting history.”). 3 In sum, the Court has considered the impact of the structural bias here and, while cognizant of it, concludes that it should not be afforded much weight in determining whether MetLife abus…

As that Court noted, “ ‘deferential review under the “arbitrary and capricious” standard is merited for decisions regarding benefits when they are made in compliance with plan procedures.’ When decisions are not in compliance with regulatory and plan procedures, deference may not be warranted.” Id. at 1105 (quoting Sanford v. Harvard Indus., *1106 262 F.3d 590 , 597 (6th Cir.2001)) (emphasis added in Jebian)-, see also Abatie, 458 F.3d at 963 (“In general, we review de novo …

See Abatie, 458 F.3d at 971 (“[U]nder Firestone, a plan administrator’s decision is entitled to deference only when the administrator exercises discretion that the plan grants as a matter. of contract.”).

Abatie, 458 F.3d at 968 (“A district court, when faced with all the facts and circumstances, must decide in each case how much or how little to credit the plan administrator’s reason for denying insurance coverage.”).

Co., 458 F.3d 955, 963 (9th Cir. 2006) (“[W]e have repeatedly held that similar 9 plan wording—granting the power to interpret plan terms and to make final benefits 10 determinations—confers discretion on the plan administrator.”).

(Doc. 46 at 8.) However, under Abatie, a conflict is treated 458 F.3d at 970 (“[T]he decision on the merits, though, must rest on the administrative record once the conflict (if any) has been established, by extrinsic evidence or otherwise.”) with id. at 973 (“[T]he court may take additional evidence when the irregularities have prevented full development of the administrative record.. . . [to], in essence, recreate what the administrative record would have been had the proc…

Id. ("Before leaving, Ms. Gorbacheva notified staff that she would not be attending the following day, October 31, because of her high level of discomfort, but would attempt to complete her second program day on Friday, November 1st.").

Co. v. Glenn, 554 U.S. 105, 117 , 128 S.Ct. 2343 , 171 L.Ed.2d 299 (2008) (noting that a conflict is “more important ... where circumstances suggest a higher likelihood that it affected the benefits decision.”); Abatie, 458 F.3d at 969 (“The level of skepticism with which a court views a conflicted administrator’s decision may be low if a structural conflict of interest is unaccompanied, for example, by any evidence of malice, of self-dealing, or of a parsimonious claims-gra…

Firestone, 489 U.S. at 115 , 109 S.Ct. 948 ; Abatie, 458 F.3d at 965 ("[TIthe existence of a conflict of interest is relevant to how a court conducts abuse of discretion review."); Montour, 588 F.3d at 630 ("Simply construing the terms of the underlying plan and scanning the record for medical evidence supporting the plan administrator's decision is not enough, because a reviewing court must take into account the administrator's conflict of interest as a factor in the analys…

However, it is undisputed in this case that, as an entity that both determines eligibility for benefits and pays benefit awards, Hartford operates under a “structural conflict of interest.” See Abatie, 458 F.3d at 965 (“an insurer that acts as both the plan administrator and the funding source for benefits operates under what may be termed a structural conflict of interest”).

Co., 458 F.3d 955, 965 (2006) (“Abuse of discretion review applies to a discretion-granting plan even if the administrator has a conflict of interest.

Abatie, 458 F.3d at 963 (“The essential first step of the analysis, then, is to examine 25 whether the terms of the ERISA plan unambiguously grant discretion to the administrator. 26 Accordingly, we first turn to the text of the plan.”); Kearney, 175 F.3d at 1089-90 (“Thus our task 27 now is to examine the instrument to determine whether it confers discretion on [the defendant] to 1 1.

App’x 530, 530-31 (9th Cir. 2014) (citing Firestone, 489 U.S. at 115 ); see also Abatie, 458 F.3d at 967 (“We read Firestone to require abuse of discretion review whenever an ERISA plan grants discretion to the plan administrator, but a review informed by the nature, extent, and effect on the decision-making process of any conflict of interest that may appear in the record.”).

Abatie, 458 F.3d at 965 (“Abuse of discretion review applies to a discretion- granting plan even if the administrator has a conflict of interest.”).

Sept. 30, 2015); see also Abatie, 458 F.3d at 967 (“We read Firestone to require abuse of discretion review whenever an ERISA plan grants discretion to the plan administrator, but a review informed by the nature, extent, and effect on the decision-making process of any conflict of interest that may appear in the record.”).

Health Plan Long Term Disability Plan, 563 Fed.Appx. 530, 530-31 (9th Cir.2014) (citing Firestone, 489 U.S. at 115 , 109 S.Ct. 948 ); see also Abatie, 458 F.3d at 967 (“We read Firestone to require abuse of discretion review whenever an ERISA plan grants discretion to the plan administrator, but a review informed by the nature, extent, and effect on the decision-making process of any conflict of interest that may appear in the record.”).

See Saffon, 522 F.3d at 872 (“[C]oming up with a new reason for rejecting the claims at the last minute suggests that the claim administrator may be casting about for an excuse to reject the claim rather than conducting an objective evaluation.”); Abatie, 458 F.3d at 974 (“[A]n administrator that adds, in its final decision, a new reason for denial, a maneuver that has the effect of insulating the rationale from review, contravenes the purpose of ERISA.”). 20.

Abatie, 458 F.3d at 965 (“Abuse of discretion review applies to a discretion-granting plan even if the administrator has a conflict of interest”).

LEXIS 100445 at *24-25 (“In theory, any number of factors might be relevant to such a determination” of whether the Plan abused its discretion in denying LTD benefits); Abatie, 458 F.3d at 968 (“abuse of discretion analysis allows a court to tailor its review to all the circumstances before it”).

Abatie, 458 F.3d at 969 (“[CJonsid-eration of new evidence is permitted only in conjunction with de novo review of á denial of benefits.”). 9 .

Co., 458 F.3d 955, 974 (9th Cir. 2006) (“[A]n administrator that adds, in its final decision, a new reason for denial, a maneuver that has the effect of insulating the rationale from review, contravenes the purpose of ERISA.”); Gagliano v. Reliance Standard Life Ins.

Co., 458 F.3d 955, 972 (9th 19 Cir. 2006) (“A procedural irregularity . . . is a matter to be weighed in deciding whether an 20 administrator’s decision was an abuse of discretion.”).

Co., 458 F.3d 955, 963 (9th Cir. 2006) (“If de novo review applies, . . . [t]he Court simply proceeds to evaluate whether the plan administrator correctly or incorrectly denied benefits.”).

Co., 458 F.3d 955, 971 (9th Cir. 2006) (“an administrator’s failure to comply with ... procedural requirements ordinarily does not alter the standard of review.”).