Abatie v. Alta Health and Life Insurance Co

In Abatie v. Alta Health and Life Insurance Co., 458 F.3d 955 (9th Cir. 2006) (en banc), the Court stated that if the administrator did not provide a full and fair hearing, as required by ERISA, 29 U.S.C. 1133(2), the court must be in a position to assess the effect of that failure and, before it can do so, must permit the participant to present additional evidence. Id. at 973. The court added that even when procedural irregularities are smaller . . . , the court may take additional evidence when the irregularities have prevented full development of the record in order for the court to recreate what the administrative record would have been had the procedure been correct. Id. In Abatie v. Alta Health & Life Ins. Co., 458 F.3d 955 (9th Cir. 2006), the Court explained that a reviewing court must always consider the inherent conflict that exists when a plan administrator both administers the plan and funds it. Id. at 967. The Court weigh such a conflict more or less heavily depending on what other evidence is available. Id. at 968. The Court view the conflict with a low level of skepticism if theres no evidence of malice, of self-dealing, or of a parsimonious claims-granting history. Id. But the Court may weigh the conflict more heavily if theres evidence that the administrator has given inconsistent reasons for denial, has failed adequately to investigate a claim or ask the plaintiff for necessary evidence, or has repeatedly denied benefits to deserving participants by interpreting plan terms incorrectly. Id. In explaining what it means to weigh a conflict of interest, Abatie consciously rejected the sliding scale approach adopted by other circuits: Weighing a conflict of interest as a factor in abuse of discretion review requires a case-by-case balance . . . . 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 administrators reason for denying insurance coverage. An egregious conflict may weigh more heavily (that is, may cause the court to find an abuse of discretion more readily) than a minor, technical conflict might. Id. at 967, 968. Abatie went on to offer additional guidance: Courts are familiar with the process of weighing a conflict of interest. For example, in a bench trial the court must decide how much weight to give to a witness testimony in the face of some evidence of bias. What the district court is doing in an ERISA benefits denial case is making something akin to a credibility determination about the insurance companys or plan administrators reason for denying coverage under a particular plan and a particular set of medical and other records. We believe that district courts are well equipped to consider the particulars of a conflict of interest, along with all the other facts and circumstances, to determine whether an abuse of discretion has occurred. Id. at 969. In Abatie, the beneficiary presented evidence in the district court bearing on the new issue, but the court refused to consider it. Id. The Court held that this was error, which must mean that a claimant in such circumstances is entitled to present evidence and to have the district court consider it.