8 Trial Lawyer • Spring 2023 Employee Benefit Claims Continued from p 7 to make a complete record by assuring her it would obtain the necessary evidence and failing to do so. Claim notes documented incomplete and misleading responses by the claim manager to Liz’s questions about her legal rights and suggested she had been dissuaded from retaining a lawyer, as she had stated. The appeal had clearly documented the manager’s assurances to Liz that she would merely need to submit a simple letter to appeal. Abuse of discretion In reviewing for an abuse of discretion under ERISA, the court will not overturn an administrator’s denial decision that is “reasonable.” Black v. Hartford Life Ins. Co., No. 3:17-CV-1785-HZ, 2019 U.S. Dist. LEXIS 96711, at *5-6 (D Or June 10, 2019); See, Salomaa v. Honda Long Term Disability Plan, 642 F.3d 666, 676 (9th Cir. 2011). However, this rule is tempered by the court’s recognition that the administrator has a conflict of interest and this “must be weighed as a factor in determining whether there is an abuse of discretion.” Id. at 674 (internal quotation marks omitted). The reviewing court considers “case-specific factors” and “reaches a decision as to whether discretion has been abused by weighing and balancing those factors together.” Montour v. Hartford Life & Accident Ins. Co., 588 F.3d 623, 630 (9th Cir. 2009) (citation omitted). Factors that frequently arise include the quality and quantity of medical evidence; whether the administrator obtained an in-person medical evaluation or merely relied on a paper file review of existing records; whether the administrator provided its consultants all relevant evidence; evidence of malice; and procedural violations of ERISA regulations. See Black, 2019 U.S. Dist. LEXIS 96711, at *8 (citations omitted). We had some good arguments that the denial decision in Liz’s case was tainted by the administrator’s conflict of interest based upon the claim notes and the fact the insurer willingly ignored and failed to obtain evidence that it knew or should have known could be material to its decision. See Abatie v. Alta Health & Life Ins. Co., 458 F.3d 955, 966-67 (9th Cir. 2006) (en banc) (“we may ‘weigh’ the conflict ‘more heavily’ if there’s evidence that the administrator…has failed ‘adequately to investigate a claim or ask the plaintiff for necessary evidence’...” (quoting Atwood v. Newmont Gold Co., 45 F.3d 1317, 1323 (9th Cir. 1995)). Conflict discovery I concluded that the claim file provided enough helpful “conflict” evidence for me to offer to pursue the case in litigation. Liz’s claim was nevertheless a very difficult one. We pursued so-called “conflict” discovery, seeking further evidence that the administrator’s conflict of interest had tainted its denial decision. See Black v. Hartford Life Ins. Co., No. 3:17-cv-01785-HZ, 2018 U.S. Dist. LEXIS 137138 (D. Or. Aug. 14, 2018) (addressing discovery standards under ERISA in “conflict” discovery motion). Eventually, Liz settled her case through a “buy-out.” She was paid a lump sum in exchange for her waiver of rights under the plan. She received a very small portion of the present value of the benefit stream she would have received had she remained disabled through the plan’s maximum benefit period, another 20 years. Her risk was too high to continue. Had Liz known she had fallen into the unfair realm of ERISA and obtained See Employee Benefit Claims p 10 In reviewing for an abuse of discretion under ERISA, the court will not overturn an administrator’s denial decision that is “reasonable.”
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