On October 27, 2010, the Ninth Circuit Court of Appeals affirmed the decision of the U.S. District Court Central District (Judge Christina A. Snyder) upholding Connecticut General Life Insurance Company's ("CGLIC") termination of Dierro Muniz's ("Muniz") disability benefits.
Muniz ("Muniz") was insured under a long-term disability insurance plan issued by CGLIC. Muniz was diagnosed with HIV in 1989 and stopped working on August 1, 1991 due to the effects of his disease. He began receiving total disability benefits under his employer's group LTD plan (the "Plan") insured by CGLIC in February 1992. Under the Plan, Muniz would continue to receive benefits after 24 months if he was "totally disabled," which is defined as "unable to perform all the essentials duties of any occupation for which [he is] or may reasonably become qualified." After requesting updated medical records from Muniz and attempting (on several occasions) to schedule a Functional Capacity Evaluation ("FCE") for Muniz (which his treating physician refused to authorize), CGLIC terminated benefits on September 8, 2006 because the medical documentation did not support the severity of his condition preventing him from performing the essential duties of any occupation.
Muniz exhausted his administrative remedies and then sued CGLIC. The parties agreed the district court's review was de novo because the CGLIC policy did not confer discretionary authority. The administrative record was insufficient to determine whether Muniz was "totally disabled" under the terms of the plan at the time his benefits were terminated. The district court asked the parties for their positions regarding appointing an independent expert to evaluate Muniz and present an opinion as to his functional capacity. The parties agreed to the order but disagreed as to the intent of the order, filing a joint request for clarification. The court confirmed that the order required designation of a functional capacity evaluator. The parties subsequently agreed upon a facility for the FCE and Muniz underwent the FCE on March 25, 2009. The district court analyzed the record with the FCE and held Muniz was not "totally disabled" under the terms of the CGLIC plan as of September 9, 2006 (the day after his benefits were terminated). Muniz appealed to the Ninth Circuit.
On appeal, Muniz argued he met the burden of proving disability by submitting evidence from his treating physician, Dr. William Towner, that he was disabled, and, therefore, the burden then shifted to CGLIC to demonstrate its decision was justified. The Ninth Circuit held the district court correctly found the burden of proof was on Muniz. In support of his position, Muniz pointed only to cases where courts reviewed claim administrator decisions under the abuse of discretion standard. Here, the district court's review was de novo. There was no authority to support Muniz's contention the burden of proof shifts to the claim administrator when it terminates disability benefits without providing any evidence that Muniz's condition had improved or changed since its initial award of benefits. The Ninth Circuit held the fact that benefits had been awarded previously may be relevant to the issue of whether Muniz was disabled and entitled to benefits at a later date, but it did not shift the burden of proof to the administrator.
The Ninth Circuit held the district court's finding Muniz did not meet the plan's definition of "totally disabled" as of a date certain was not clearly erroneous. Muniz did not provide sufficient evidence to demonstrate the district court committed clear error in its analysis of the record. Furthermore, the Ninth Circuit held the district court was not required to accord special weight to the opinions of Muniz's physician. See Black & Decker Disability Plan v Nord, 538 U.S. 822, 834 (2003). Furthermore, Muniz did not provide significant factual support to rebut the district court's finding that Dr. Towner's records were inconsistent, incomplete, and did not ultimately support Muniz's claim.
Muniz argued the district court erred by ordering him to participate in an FCE in March 2009 and subsequently considering the results of the March 2009 examination as relevant to his condition when his benefits were terminated in September 2006. The Ninth Circuit held that because the court exercised de novo review of an ERISA benefits denial decision, it was not limited to the written reasons the insurer gave Muniz for denying benefits, and therefore could consider additional evidence when circumstances clearly established such evidence was necessary to conduct an adequate de novo review. Monqeluzo v Baxter Travenol Long Term Disability Benefit Plan 46 F.3d 938 944 (9th Cir. 1995).
Muniz further argued he was denied a "full and fair review" of his claim because he was not given the opportunity to present evidence that FCEs are flawed and his March 2009 FCE was flawed. The Ninth Court held Muniz had adequate opportunity to object to the FCE and did not do so. With respect to his argument that the FCE results were irrelevant as to this issue of disability as of September 9, 2006, the Ninth Circuit held the district court was cognizant the FCE was a "snap shot of performance of Muniz's capacity" and did not rely solely on the results in rendering its decision.
The Ninth Circuit affirmed the decision of the district court, holding Muniz did not meet the burden of proving he was "totally disabled" under the terms of the CGLIC plan as of September 9, 2006.
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