Robert Montour v. Hartford Life & Accident Insur ( 2009 )

FOR PUBLICATION
UNITED STATES COURT OF APPEALS
FOR THE NINTH CIRCUIT
ROBERT MONTOUR, an individual;  No. 08-55803
TINA MONTOUR, an individual, D.C. No.
Plaintiffs-Appellants, 2:07-cv-05215-DSF-
v. RZ
HARTFORD LIFE & ACCIDENT ORDER
INSURANCE COMPANY, AMENDING
a Connecticut Corporation,
Defendant-Appellee.  OPINION AND
DENYING
PETITION FOR
REHEARING AND
PETITION FOR
REHEARING EN
BANC AND
AMENDED
 OPINION
Appeal from the United States District Court
for the Central District of California
Dale S. Fischer, District Judge, Presiding
Argued and Submitted
June 1, 2009—Pasadena, California
Filed September 14, 2009
Amended November 19, 2009
Before: William A. Fletcher, Richard R. Clifton and
Milan D. Smith, Jr., Circuit Judges.
Opinion by Judge Clifton
15367
15370 MONTOUR v. HARTFORD LIFE & ACCIDENT
COUNSEL
Bradley P. Knypstra, Knypstra & Associates, Irvine, Califor-
nia, for the plaintiffs-appellants.
Bruce D. Celebrezze, Dennis G. Rolstad (argued) and Erin A.
Cornell, Sedgwick, Detert, Moran & Arnold LLP, San Fran-
cisco, California, for the defendant-appellee.
ORDER
The opinion in this case, filed September 14, 2009, is
amended by revising the first sentence of the paragraph that
starts at the bottom of page 13360 of the slip opinion and
extends onto page 13361. The sentence previously started:
MONTOUR v. HARTFORD LIFE & ACCIDENT 15371
In clarifying the standard of review, Abatie also
abrogated a line of cases, including Jordan v. North-
rop Grumman Corporation Welfare Benefit Plan,
370 F.3d 869 (9th Cir. 2004), and Bendixen v. Stan-
dard Insurance Company, 185 F.3d 939 (9th Cir.
1999), that had directed reviewing courts . . . .
That sentence is amended as follows:
In clarifying the standard of review, Abatie abro-
gated a line of cases, including Jordan v. Northrop
Grumman Corporation Welfare Benefit Plan, 370
F.3d 869 (9th Cir. 2004), and Bendixen v. Standard
Insurance Company, 185 F.3d 939 (9th Cir. 1999),
to the extent that the cases directed reviewing courts
....
With this amendment, the panel has voted to deny the peti-
tion for rehearing and petition for rehearing en banc.
The full court has been advised of the petition for rehearing
en banc, and no judge of the court has requested a vote on it.
Fed. R. App. P. 35.
The petition for rehearing and petition for rehearing en
banc, filed October 13, 2009, are DENIED. No further peti-
tions for rehearing or for rehearing en banc may be filed.
OPINION
CLIFTON, Circuit Judge:
This case presents the question of how a district court
should apply the abuse of discretion standard when reviewing
a decision by the administrator of an employee benefits plan
governed by the Employee Retirement Income Security Act
15372 MONTOUR v. HARTFORD LIFE & ACCIDENT
of 1974 (ERISA), 88 Stat. 829, as amended, 29 U.S.C.
§§ 1001-1461, when that administrator has a conflict of inter-
est. We conclude that a reviewing court must take into
account the conflict and that this necessarily entails a more
complex application of the abuse of discretion standard. Spe-
cifically, a modicum of evidence in the record supporting the
administrator’s decision will not alone suffice in the face of
such a conflict, since this more traditional application of the
abuse of discretion standard allows no room for weighing the
extent to which the administrator’s decision may have been
motivated by improper considerations.
Robert Montour appeals the district court’s order granting
summary judgment in favor of Hartford Life and Accident
Insurance Company in his action challenging Hartford’s deci-
sion to terminate his long-term disability benefits as an abuse
of its discretion. We reverse and, applying the proper standard
of review to the facts of this case, conclude that Hartford
abused its discretion because its conflict of interest too heav-
ily influenced its termination decision. Accordingly, we
remand to the district court for an order reinstating Montour’s
long-term disability benefits.
I. Background
As an employee of Conexant Systems, Inc. for approxi-
mately thirty-seven years, Montour participated in his
employer’s group long-term disability insurance plan, which
is a welfare benefit plan governed by ERISA. Hartford is both
the insurer and the administrator of the Plan. The Plan grants
Hartford, as the administrator, discretionary authority to inter-
pret Plan terms and to determine eligibility for benefits,1 and
1
Specifically, the policy provides:
Who interprets policy terms and conditions?
We [Hartford] have full discretion and authority to determine eli-
gibility for benefits and to construe and interpret all terms and
provisions of the Group Insurance Policy.
MONTOUR v. HARTFORD LIFE & ACCIDENT 15373
it places the burden of proving both initial and ongoing dis-
ability on the claimant.
In July 2003 Montour took a medical leave of absence from
his position as a telecommunications manager after develop-
ing symptoms of acute stress disorder. At the time, he was
fifty-five years old. In January 2004, following a period of
180 days during which no benefits were payable under the
Plan, Hartford accepted Montour’s application for benefits
under the Plan and began paying him disability benefits.
At the outset of his psychiatric illness, Montour consulted
several times with his primary care physician, Dr. Samuel
Park. In September 2003 he began regular psychotherapy ses-
sions with a psychiatrist. His last documented psychotherapy
session took place in April 2005.
Meanwhile, in June 2004 Montour consulted Dr. Kenneth
Kengla, an orthopedic surgeon, about pain in his right knee
and his lower back. Dr. Kengla diagnosed Montour with
degenerative changes in both regions and notified Hartford in
September 2004 that Montour was at that time also suffering
from physical disability that prevented him from returning to
the labor force. In October 2004 Dr. Kengla performed
arthroscopic surgery on Montour’s right knee. The subject of
Montour’s back condition did not come up again during their
consultations until April 2005. Subsequently, Montour con-
sulted Dr. Kengla about his back pain during appointments in
December 2005 and May 2006.
Dr. Kengla consistently maintained to Hartford that Mon-
tour remained physically disabled and unable to work in any
job as a result of his back and knee impairments. Specifically,
he listed the following restrictions on Montour’s physical
activities: 1) “no sitting for more than 15-20 min[utes] at a
time”; 2) “no prolonged walking”; 3) “no standing greater
than 15 min[utes] at a time”; 4) “no lifting or carrying greater
than 10 [pounds;]” 4) “no work at or above shoulder level”;
15374 MONTOUR v. HARTFORD LIFE & ACCIDENT
5) “no moderate pushing activities”; 6) “no moderate pulling
activities”; and 7) “no driving greater than 30 min[utes] at a
time.”
In November and December 2005 Hartford hired two out-
side companies to conduct surveillance on Montour over the
course of four nonconsecutive days. Video footage from this
surveillance depicted Montour driving his car to perform
occasional errands, such as picking up his grandchildren from
school, going to the pharmacy, and getting a haircut. He was
observed once bending at the waist to reach into his car.
In March 2006 a Hartford investigator conducted a personal
interview with Montour at his home, during which Montour
listed a “bad back, [an] arthritic right knee, and sleep apnea”
as the “disabling medical condition(s)” preventing him from
returning to work. He also described an inability to concen-
trate, which he attributed to the medication he must take to
treat his “constant pain.” The investigator observed that Mon-
tour remained alert and responsive during the entire four-and-
a-half hour interview, although he called the investigator by
the wrong name about two hours into the interview. Montour
acknowledged that the surveillance video footage accurately
depicted his level of functionality. He was physically able to
complete the interview, but he demonstrated signs of pain in
front of the investigator, such as moaning when he stood up
or twisted, walking around his house stiffly with a slight limp,
and complaining of back pain three times during the final two
hours.
In May 2006 a Hartford nurse case manager submitted let-
ters to Dr. Kengla and Dr. Park surmising that Montour was
capable of performing “sedentary to light” work and soliciting
their agreement. Dr. Park signed and returned the letter, which
signified that he either agreed or found “no contraindications
to this work capacity level.” Dr. Kengla, on the other hand,
indicated that he disagreed with Hartford’s conclusions, citing
MONTOUR v. HARTFORD LIFE & ACCIDENT 15375
Montour’s persistent orthopedic symptoms and physical
restrictions.
In July 2006 Hartford hired a consulting physician, Dr.
Gale Brown, to conduct a file review. Dr. Brown analyzed
Montour’s medical records for the 2003-2006 period, includ-
ing X-rays and MRIs of Montour’s lower back taken in June
2004 and May 2006, Montour’s pharmacy records for the
2004-2006 period, Hartford’s surveillance video and accom-
panying reports, and the personal interview report. He also
spoke with Dr. Kengla on the phone. Dr. Brown concluded
that medical evidence supported the existence of a lower back
condition called “degenerative spondylostenosis/DDD” but
that Dr. Kengla’s offered restrictions were excessive for this
“mild to moderate” condition and understated Montour’s
demonstrated and admitted physical abilities. Dr. Brown
acknowledged that medical evidence supported Montour’s
chronic pain but found that Montour was nevertheless capable
of working full-time with modest restrictions, such as chang-
ing positions every thirty to forty-five minutes.
Hartford next enlisted a vocational rehabilitation expert to
compile an Employability Analysis Report, which evaluated
Montour’s experience, qualifications, and the physical restric-
tions identified by Dr. Brown. That expert concluded that
Montour was capable of working in a high-level managerial
capacity in five different fields.
In August 2006 Hartford informed Montour of its decision
to terminate his benefits in light of its conclusion that he no
longer met the policy’s definition of disability. Montour
appealed this decision internally and included a vocational
appraisal report by Gene Bruno. The Bruno report concluded
that Montour was “not employable in any setting” and that
Hartford’s decision was based on numerous mistakes, includ-
ing a disregard for the fact that the Social Security Adminis-
tration (SSA) considered Montour to be “totally disabled.”
15376 MONTOUR v. HARTFORD LIFE & ACCIDENT
In response, Hartford hired Dr. Renat Sukhov to conduct a
second file review. Dr. Sukhov reviewed Montour’s records
for evidence of a physical condition that would preclude sed-
entary work and, like Dr. Brown, found none. He noted in
particular a lack of objective, clinical data demonstrating the
extent to which Montour’s pain impacted his functionality. He
also noted that Montour’s activities depicted on the surveil-
lance videos exceed the activity requirements of a sedentary
job. Dr. Sukhov concluded that Montour could work, at mini-
mum, in a sedentary job with reasonable restrictions, such as
avoiding static work posture, not lifting objects weighing
more than twenty pounds, and not pushing or pulling loads
weighing more than thirty to thirty-five pounds.
In light of concerns raised in the Bruno report, Hartford
also requested a vocational specialist to conduct an Employ-
ability Analysis Report addendum, which reached the same
conclusion as the Employability Analysis Report regarding
the sedentary nature and thus the feasibility of the five pro-
posed managerial positions. In February 2007 a Hartford
appeal specialist affirmed the company’s previous decision to
terminate Montour’s benefits.
Having exhausted his administrative remedies, in June
2007 Montour and his wife, Tina Montour, filed suit against
Hartford in California Superior Court to recover benefits
under ERISA § 502(a)(1)(B), 29 U.S.C. § 1132(a)(1)(B). The
complaint also alleged breach of fiduciary duty, promissory
estoppel, invasion of privacy, intentional infliction of emo-
tional distress, and loss of consortium. Hartford removed the
case to the Central District of California and promptly moved
to dismiss. The district court dismissed the causes of action
for breach of fiduciary duty and promissory estoppel,
remanded the claims for invasion of privacy, intentional
infliction of emotional distress, and loss of consortium back
to state court, and proceeded to hold a bench trial on the
administrative record for the remaining ERISA benefits
recovery claim.
MONTOUR v. HARTFORD LIFE & ACCIDENT 15377
In April 2008 the court entered its Findings of Fact and
Conclusions of Law ordering Judgment in favor of Hartford.
The district court concluded that although Hartford had a
structural conflict of interest in its position as both the admin-
istrator of the insurance policy and the payor of benefits, it did
not abuse its discretion in determining that Montour failed to
provide sufficient evidence to demonstrate disability within
the meaning of the policy.
Montour timely appealed.
II. Standard of Review
The district court’s findings of fact in a bench trial on the
administrative record are reviewed under the clearly errone-
ous standard. See Pannebecker v. Liberty Life Assurance Co.
of Boston, 542 F.3d 1213, 1217 (9th Cir. 2008); see also
Kearney v. Standard Ins. Co., 175 F.3d 1084, 1095 & n.6 (9th
Cir. 1999) (en banc). In contrast, we review “a district court’s
choice and application of the appropriate standard for review-
ing benefits decisions by an ERISA plan administrator” de
novo. Sznewajs v. U.S. Bancorp Amended & Restated Supple-
mental Benefits Plan, 572 F.3d 727, 732 (9th Cir. 2009)
(internal quotation marks omitted).
As for review of a plan administrator’s decision, “[t]he
Supreme Court has held that a denial of benefits ‘is to be
reviewed under a de novo standard unless the benefit plan
gives the administrator . . . discretionary authority to deter-
mine eligibility for benefits or to construe the terms of the
plan.’ ” Burke v. Pitney Bowes Inc. Long-Term Disability
Plan, 544 F.3d 1016, 1023 (9th Cir. 2008) (quoting Firestone
Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989)).
Where, as here, the plan “does grant such discretionary
authority, we review the administrator’s decision for abuse of
discretion.” Saffon v. Wells Fargo & Co. Long Term Disabil-
ity Plan, 522 F.3d 863, 866 (9th Cir. 2008). The manner in
which a reviewing court applies the abuse of discretion stan-
15378 MONTOUR v. HARTFORD LIFE & ACCIDENT
dard, however, depends on whether the administrator has a
conflicting interest.
[1] In the absence of a conflict, judicial review of a plan
administrator’s benefits determination involves a straightfor-
ward application of the abuse of discretion standard. See
Sznewajs, 572 F.3d at 733-35; Boyd v. Bert Bell/Pete Rozelle
NFL Players Ret. Plan, 410 F.3d 1173, 1178-79 (9th Cir.
2005). In these circumstances, the plan administrator’s deci-
sion can be upheld if it is “grounded on any reasonable basis.”
See Sznewajs, 572 F.3d at 734-35 (internal quotation marks
omitted). In other words, where there is no risk of bias on the
part of the administrator, the existence of a “single persuasive
medical opinion” supporting the administrator’s decision can
be sufficient to affirm, so long as the administrator does not
construe the language of the plan unreasonably or render its
decision without explanation. See Boyd, 410 F.3d at 1179; see
also Sznewajs 572 F.3d at 733-35.
[2] Commonly, however, the same entity that funds an
ERISA benefits plan also evaluates claims, as is the case here.
See Metro. Life Ins. Co. v. Glenn, 128 S. Ct. 2343, 2346, 2348
(2008) (“MetLife II”).2 Under these circumstances, the plan
administrator faces a structural conflict of interest: since it is
also the insurer, benefits are paid out of the administrator’s
own pocket, so by denying benefits, the administrator retains
money for itself. Application of the abuse of discretion stan-
dard therefore requires a more complex analysis. See Abatie
v. Alta Health & Life Ins. Co., 458 F.3d 955, 965 (9th Cir.
2006) (en banc) (“[T]he existence of a conflict of interest is
relevant to how a court conducts abuse of discretion review.”
(emphasis added)). Simply construing the terms of the under-
lying plan and scanning the record for medical evidence sup-
porting the plan administrator’s decision is not enough,
because a reviewing court must take into account the adminis-
2
We refer to the Supreme Court’s decision as “MetLife II” because we
also reference the lower court’s opinion, infra, which MetLife II affirmed.
MONTOUR v. HARTFORD LIFE & ACCIDENT 15379
trator’s conflict of interest as a factor in the analysis. See
MetLife II, 128 S. Ct. at 2346, 2348, 2350; Abatie, 458 F.3d
at 968-69.
[3] More particularly, the court must consider numerous
case-specific factors, including the administrator’s conflict of
interest, and reach a decision as to whether discretion has
been abused by weighing and balancing those factors
together. See MetLife II, 128 S. Ct. at 2351-52 (describing the
garden variety “combination-of-factors method of review”).
Under this rubric, the extent to which a conflict of interest
appears to have motivated an administrator’s decision is one
among potentially many relevant factors that must be consid-
ered. Other factors that frequently arise in the ERISA context
include the quality and quantity of the medical evidence,
whether the plan administrator subjected the claimant to an
in-person medical evaluation or relied instead on a paper
review of the claimant’s existing medical records, whether the
administrator provided its independent experts “with all of the
relevant evidence[,]” and whether the administrator consid-
ered a contrary SSA disability determination, if any.3 See
MetLife II, 128 S. Ct. at 2352; see also Saffon, 522 F.3d at
869-73.
The weight the court assigns to the conflict factor depends
on the facts and circumstances of each particular case. For
example, the Supreme Court has explained that this factor
should prove more important (perhaps of great
importance) where circumstances suggest a higher
3
For example, in MetLife II the Supreme Court endorsed the approach
taken by the Sixth Circuit, which weighed three factors, namely, the medi-
cal evidence, a contrary SSA disability determination, and the administra-
tor’s inherent conflict of interest, and ultimately concluded that the
administrator had abused its discretion in denying benefits to the claimant.
See Glenn v. MetLife, 461 F.3d 660, 666-74 (6th Cir. 2006) (“MetLife I”),
aff’d by MetLife II, 128 S. Ct. at 2351-52 (finding “nothing improper in
the way in which the [Sixth Circuit] conducted its review”).
15380 MONTOUR v. HARTFORD LIFE & ACCIDENT
likelihood that it affected the benefits decision,
including, but not limited to, cases where an insur-
ance company administrator has a history of biased
claims administration. It should prove less important
(perhaps to the vanishing point) where the adminis-
trator has taken active steps to reduce potential bias
and to promote accuracy, for example, by walling off
claims administrators from those interested in firm
finances, or by imposing management checks that
penalize inaccurate decisionmaking irrespective of
whom the inaccuracy benefits.
MetLife II, 128 S. Ct. at 2351 (internal citation omitted and
emphases added); see also Abatie, 458 F.3d at 967 (holding
that in weighing a conflict of interest, the court’s discretionary
review must be “informed by the nature, extent, and effect”
that conflict may have had “on the decision-making process”).
Our court has implemented this approach by including the
existence of a conflict as a factor to be weighed, adjusting the
weight given that factor based on the degree to which the con-
flict appears improperly to have influenced a plan administra-
tor’s decision. See Abatie, 458 F.3d at 968; see also Nolan v.
Heald College, 551 F.3d 1148, 1153-54 (9th Cir. 2009); Saf-
fon, 522 F.3d at 867-68. These cases should not be mistaken
to imply that the existence of a conflict of interest alters the
standard of review itself, rather than merely its application.
As Abatie explicitly held, if a conflict of interest exists,
“abuse of discretion review applies” and “that conflict must
be weighed as a factor in determining whether there is an
abuse of discretion.” 458 F.3d at 965 (internal quotation
marks and alteration omitted). In fact, Abatie “conscious[ly]
reject[ed]” the “sliding scale metaphor” that some other cir-
cuits had adopted, which involved adjusting the level of “def-
erence” 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 con-
MONTOUR v. HARTFORD LIFE & ACCIDENT 15381
sidered, and nothing ‘slides[.]’ ”). This comports with the
Supreme Court’s more recent pronouncement “that a review-
ing court should consider [a] conflict as a factor in determin-
ing whether the plan administrator has abused its discretion in
denying benefits[,] and that the significance of the factor will
depend upon the circumstances of the particular case.”
MetLife II, 128 S. Ct. at 2346.
[4] In any event, Abatie explained that the court should
adjust the level of skepticism with which it reviews a poten-
tially biased plan administrator’s explanation for its decision
in accordance with the facts and circumstances of the case.
See 458 F.3d at 969; see also Saffon, 522 F.3d at 868. If those
facts and circumstances indicate the conflict may have tainted
the entire administrative decisionmaking process, the court
should review the administrator’s stated bases for its decision
with enhanced skepticism: this is functionally equivalent to
assigning greater weight to the conflict of interest as a factor
in the overall analysis of whether an abuse of discretion
occurred.
[5] In clarifying the standard of review, Abatie abrogated
a line of cases, including Jordan v. Northrop Grumman Cor-
poration Welfare Benefit Plan, 370 F.3d 869 (9th Cir. 2004),
and Bendixen v. Standard Insurance Company, 185 F.3d 939(9th Cir. 1999), to the extent that the cases directed reviewing
courts to disregard structural conflicts of interest and affirm
an administrative decision “grounded on any reasonable
basis,” unless a plaintiff could produce sufficient evidence
that the conflict was “serious.” See Abatie, 458 F.3d at 966-
67, 969. This more traditional application of the abuse of dis-
cretion standard allowed no room for a reviewing court to fac-
tor the existence of a conflict of interest into the analysis. See
Jordan, 370 F.3d at 878-80; Bendixen, 185 F.3d at 944. In the
wake of Abatie, therefore, the traditional application of
administrative discretionary review that our court still applies
in cases where no conflict exists does not apply to the review
of a decision by an inherently conflicted plan administrator.
15382 MONTOUR v. HARTFORD LIFE & ACCIDENT
See, e.g., Sznewajs, 572 F.3d at 734-36 (holding that “[u]nder
the deferential standard which courts must use to review the
administrator’s interpretation in the absence of any evidence
of conflict of interest,” the “plan administrator’s decision to
deny benefits must be upheld under the abuse of discretion
standard if it is based upon a reasonable interpretation of the
plan’s terms and if it was made in good faith” (internal quota-
tion marks omitted and emphasis added)).
For this reason, the district court’s reliance in this case on
Boyd, another decision in which there was apparently no evi-
dence of a conflict of interest, was incorrect. See 410 F.3d at
1178-79. The district court acknowledged there were “signs
of bias in Hartford’s determination” but, applying Boyd,
deemed itself capable of reversing Hartford’s decision as an
abuse of discretion “only . . . if it [found] clear error in Hart-
ford’s determination” that Montour failed to provide suffi-
cient evidence to demonstrate his disability. (Emphasis
added.) While the district court found that Hartford’s conflict
of interest tainted much of the administrative decisionmaking
process, its “analysis of the plan administrator’s basis for ter-
minating benefits does not include any discussion of the role
that . . . conflict of interest may have played in [Hartford]’s
decision nor appear to give that conflict any weight.” MetLife
I, 461 F.3d at 666. Likewise, the court acknowledged the dis-
sonance between the SSA’s disability determination and Hart-
ford’s contrary conclusion, but it does not appear to have
given this factor adequate consideration or weighed it against
other factors. Instead, the court relied on Boyd, a case involv-
ing no conflict and thus a less complex application of the
abuse of discretion standard, to conclude that no abuse of dis-
cretion occurred because the record contained some medical
evidence supporting Hartford’s decision to deny benefits. In
fact, the language of the district court’s decision suggests that
because of that evidence, the court felt itself obliged to affirm,
irrespective of any taint. After Abatie, this is incorrect.
MONTOUR v. HARTFORD LIFE & ACCIDENT 15383
[6] As the district court’s decision did not appropriately
balance the pertinent factors, and in particular the conflict fac-
tor, we proceed to do so here. Judicial review of an ERISA
plan administrator’s decision on the merits is limited to the
administrative record,4 so “we are in the same position as the
district court . . . .” See Moapa Band of Paiute Indians v. U.S.
Dep’t of Interior, 747 F.2d 563, 565 (9th Cir. 1984); see also,
e.g., Ranchers Cattlemen Action Legal Fund United Stock-
growers of Am. v. U.S. Dep’t of Agric., 499 F.3d 1108, 1114-
15 (9th Cir. 2007) (reaching the merits in a case requiring
administrative record review because the court of appeals
faced the same task as the district court did). Therefore, while
we accept the district court’s factual findings, we apply the
standard of review de novo. See Ramstad v. Hodel, 756 F.2d
1379, 1382 (9th Cir. 1985).
III. The Merits
[7] We begin with the district court’s comprehensive
description of the “signs of bias” exhibited by Hartford
throughout its decisionmaking process:
Hartford was both the plan administrator and funder
of the Plan, and evidence of this conflict of interest
appears throughout the record. For example, in its
letters to Plaintiff, Hartford overstates and over-
relies on surveillance of Plaintiff. Plaintiff was
observed over forty daylight hours on four days in
November and December 2005. During this time, he
was observed making two twenty minute trips to
pick up or drop off his grandchildren from school
and one trip of about two and a half hours conduct-
ing errands at various stores. He was also observed
to be away from his home on two occasions for
4
In the ERISA context, the “administrative record” consists of “the
papers the insurer had when it denied the claim.” See Kearney, 175 F.3d
at 1086.
15384 MONTOUR v. HARTFORD LIFE & ACCIDENT
about an hour and forty minutes. During this time, he
was observed bending once at the waist and picking
up a small bag of medication.
This observed activity was brief and consistent
with Plaintiff ’s self-reported limitations. Plaintiff
admitted that he was able to drive for up to thirty
minutes, could walk short distances, and could lift
objects lighter than five pounds. Yet Hartford
claimed that Plaintiff ’s “self-reported limitations
were not consistent with his observed activities.”
Hartford strung together a laundry list of discrete
activities observed over the course of four days, sug-
gesting that Plaintiff was capable of sustaining those
activities throughout the day, as would be required in
a sedentary occupation. However, that Plaintiff could
perform sedentary activities in bursts spread out over
four days does not indicate that he [ ]is capable of
sustaining activity in a full-time occupation.
Furthermore, despite its own internal observation
that Plaintiff walked “in a slightly stiff and slow
manner” and entered his car in “a somewhat slow
and deliberate manner”, Hartford indicates that
Plaintiff “did not show any limitation in his move-
ment and demonstrated no sign of physical distress.”
This statement is also inconsistent with Hartford’s
report on the in-home interview, which noted that
Plaintiff showed signs of pain and discomfort, moan-
ing the majority of times that he stood or twisted.
Hartford’s attempts to obtain information from
Plaintiff ’s physicians were marred by this overstate-
ment of the surveillance findings, as well as apparent
advocacy for the position that Plaintiff was not dis-
abled. In the letter sent to Drs. Park and Kengla,
Hartford again strung together discrete activities
observed in short bursts over several days, stated that
MONTOUR v. HARTFORD LIFE & ACCIDENT 15385
he was seen “walking at a brisk pace,” and noted that
his activities were “performed without apparent dif-
ficulty, hesitation, or the use of assistive devices.”
Instead of noting the observations of pain seen dur-
ing Plaintiff ’s in-home interview, the letter stated
that Plaintiff “displayed minimal physical or mental
limitation” while participating in the interview.
In response to this letter, Dr. Park, who saw Plain-
tiff twice a year and was not treating him for his
back condition, stated that he either agreed or found
no contraindication to the sedentary work capacity
suggested by Hartford. Dr. Kengla, who saw Plain-
tiff once a month for the conditions that rendered
him disabled, stated that Plaintiff remained disabled.
Dr. Park was apparently less familiar with Plain-
tiff ’s condition and thus more apt to be swayed by
Hartford’s slanted presentation of the facts. Nonethe-
less, Hartford found the disagreement between Dr.
Park and Dr. Kengla to be significant, and sent
Plaintiff ’s file to Dr. Brown for independent review.
Although he based his opinion on a number of
factors, Dr. Brown relied on both the surveillance
and the conflict of opinion between Drs. Park and
Kengla in reaching the conclusion that Plaintiff was
able to return to work. In conducting a further review
of Plaintiff ’s medical records after Plaintiff
appealed the denial of benefits, Dr. Sukhov again
overemphasized the surveillance, stating that the
“video clearly shows the claimant performing activi-
ties above those required for a sedentary job.” As
noted above, this was clearly not the case.
Thus, there is a common theme, both in Hartford’s
communications with Plaintiff and in the assess-
ments of those professionals Hartford hired to evalu-
ate Plaintiff ’s condition, of presenting evidence of
15386 MONTOUR v. HARTFORD LIFE & ACCIDENT
capability in the best possible light, while failing to
subject evidence of capability to the same skepticism
and rigorous analysis applied to evidence of disabil-
ity.
(Alterations and internal citations omitted). In other words,
Hartford’s bias infiltrated the entire administrative decision-
making process, which leads us to accord significant weight
to the conflict.
[8] Another factor is Hartford’s failure to present extrinsic
evidence of any effort on its part to “assure accurate claims
assessment[,]” such as utilizing procedures to help ensure a
neutral review process. See MetLife II, 128 S. Ct. at 2351. To
the contrary, in fact, Hartford’s nurse case manager took an
advocacy position in her letters to Montour’s physicians solic-
iting their agreement with her disability conclusion. While
Hartford was not required to present evidence demonstrating
its efforts to achieve claims administration neutrality, the
Supreme Court’s decision in MetLife II placed it on notice as
to the potential significance of such evidence in defense of a
suit by a claimant challenging an adverse benefits determina-
tion. See id. at 2351; cf. id. at 2356 (Kennedy, J., concurring
in part and dissenting in part). On the other hand, Montour
also did not submit any extrinsic evidence of bias, such as sta-
tistics regarding Hartford’s rate of claims denials or how fre-
quently it contracts with the file reviewers it employed in this
case. See id. at 2351; Abatie, 458 F.3d at 968-69; cf. Nolan,
551 F.3d at 1152 & n.3.
[9] Another factor is Hartford’s decision to conduct a “pure
paper” review in this case, that is, to hire doctors to review
Montour’s files rather than to conduct an in-person medical
evaluation of him. While the Plan does not require a physical
exam by a non-treating physician, in this case that choice
“raise[s] questions about the thoroughness and accuracy of the
benefits determination[,]” Bennett v. Kemper Nat’l Servs.,
Inc., 514 F.3d 547, 554 (6th Cir. 2008) (quotation marks
MONTOUR v. HARTFORD LIFE & ACCIDENT 15387
omitted), as it is not clear the Plan presented Dr. Brown and
Dr. Sukhov “with all of the relevant evidence.” MetLife II,
128 S. Ct. at 2352. Specifically, neither of Hartford’s profes-
sional experts mentioned the SSA’s contrary conclusion, “not
even to discount or disagree with it, which indicates that
[they] may not even have been aware of it.” See MetLife I,
461 F.3d at 669 (internal quotation marks and alterations
omitted).
In its decision to terminate Montour’s benefits, Hartford
relied significantly on the conclusions reached by Dr. Brown
and Dr. Sukhov. Dr. Brown, who conducted the first file
review, diagnosed Montour with a “mild to moderate” back
condition that he felt should not cause Montour as much pain
as he was reportedly suffering. Likewise, the second file
reviewer, Dr. Sukhov, based his conclusion of non-disability
in part on the lack of objective medical data to support Mon-
tour’s alleged pain levels, in addition to the lack of a self-
reported pain scale or some form of quantification of the
impact of his pain on his functional abilities. It would proba-
bly have been unreasonable for Hartford to require Montour
to produce objective proof of his pain level, per Dr. Sukhov,
or to reject his subjective claims of “excess pain” based solely
on Dr. Brown’s observation. See Smolen v. Chater, 80 F.3d
1273, 1281-82 (9th Cir. 1996); Fair v. Bowen, 885 F.2d 597,
601-03 (9th Cir. 1989); see also Saffon, 522 F.3d at 872-73
& n.3. However, Dr. Brown and Dr. Sukhov also observed
that: (1) Montour’s pharmacy records indicate he was using
limited and relatively mild pain medication; and (2) his medi-
cal records with Dr. Kengla suggest that he had not recently
engaged in any pain treatment programs. These observations
probably constitute sufficient “objective” evidence to support
their conclusion that Montour’s pain does not rise to the level
of disabling pain. See Orn v. Astrue, 495 F.3d 625, 637-38
(9th Cir. 2007); Fair, 885 F.2d at 602-03.
On the other hand, Dr. Sukhov also fixated on the lack of
progression (i.e., lack of further degeneration) in Montour’s
15388 MONTOUR v. HARTFORD LIFE & ACCIDENT
back condition, as evidenced by X-rays and MRIs taken in
June 2004 and May 2006, and Hartford noted this in its deci-
sion on appeal. It is not clear “why further degeneration is
necessary to sustain a finding that [Montour] is disabled.” Saf-
fon, 522 F.3d at 871. Given that Hartford found Montour dis-
abled in 2004 and paid him benefits for over two years, “[i]n
order to find [him] no longer disabled, one would expect the
MRIs to show an improvement, not a lack of degeneration.”
Id.[10] One final factor is Hartford’s failure to grapple with
the SSA’s contrary disability determination. The Plan requires
claimants to apply for social security disability benefits from
the SSA and, if denied, to exhaust all possible appeals. Hart-
ford emphasized this requirement to Montour in its initial
award letter and then again in a separate letter the following
month. In March 2004, the SSA concluded that Montour was
disabled and awarded him disability benefits retroactively to
January 2004. Hartford benefitted from this award signifi-
cantly, as it received a dollar-for-dollar financial offset, nearly
halving its liability. As of April 2005 and December 2006, the
SSA considered Montour’s disability to be “continuing.” In
August 2006, Hartford nevertheless concluded that Montour
was no longer disabled. Although Montour had immediately
forwarded the SSA’s April 2005 notice of continuing disabil-
ity to Hartford, the plan administrator made no mention of the
SSA’s contrary determination in its initial termination deci-
sion. In its decision denying Montour’s appeal, Hartford
acknowledged the SSA’s decision but did not articulate why
the SSA might have reached a different conclusion. See
MetLife I, 461 F.3d at 671 n.3 (noting that there is a distinc-
tion between mentioning a contrary determination and dis-
cussing it).
[11] While ERISA plan administrators are not bound by the
SSA’s determination, complete disregard for a contrary con-
clusion without so much as an explanation raises questions
about whether an adverse benefits determination was “the
MONTOUR v. HARTFORD LIFE & ACCIDENT 15389
product of a principled and deliberative reasoning process.”
See MetLife I, 461 F.3d at 674; see also MetLife II, 128 S. Ct.
at 2352; cf. id. at 2361 (Scalia, J., dissenting). In fact, not dis-
tinguishing the SSA’s contrary conclusion may indicate a fail-
ure to consider relevant evidence. See MetLife II, 128 S. Ct.
at 2355 (Roberts, C.J., concurring in part and concurring in
the judgment).
Unlike the SSA, Hartford was not bound by the treating
physician rule, which accords “special weight” to the opinions
of a claimant’s treating physician. See Black & Decker Dis-
ability Plan v. Nord, 538 U.S. 822, 825, 831, 834 (2003)
(holding that while ERISA administrators may not arbitrarily
ignore a treating physician’s opinion, that opinion also is not
entitled to any “special deference”). However, this distinction
alone does not provide a basis for disregarding the SSA’s
determination altogether, because in some cases, such as this
one, the SSA deploys a more stringent standard for determin-
ing disability than does the governing ERISA plan. See, e.g.,
MetLife I, 461 F.3d at 668 & n.1; Calvert v. Firstar Fin., Inc.,
409 F.3d 286, 294 n.4 (6th Cir. 2005). Specifically, after
twenty-four months the Plan defines “disability” as being pre-
vented by, inter alia, accidental bodily injury or sickness from
performing an essential duty of any occupation for which the
claimant is “qualified by education, training or experience”
that pays at least as much as the claimant would otherwise be
eligible for if receiving benefits under the Plan, which con-
sists of a formula based in part on the claimant’s past earn-
ings. The SSA’s standard is more strict, defining “disability”
as the “inability to engage in any substantial gainful activity
by reason of any medically determinable physical . . . impair-
ment” that is of “such severity that [the claimant] . . . cannot,
considering his age, education, and work experience, engage
in any other kind of substantial gainful work which exists in
the national economy, regardless of whether such work exists
in the immediate area in which he lives.” 42 U.S.C.
§ 423(d)(1)(A), (2)(A). In other words, unlike the Plan, the
SSA’s standard does not take into account a claimant’s past
15390 MONTOUR v. HARTFORD LIFE & ACCIDENT
earnings or location. Accord MetLife I, 461 F.3d at 668 n.1;
cf. DeLisle v. Sun Life Assurance Co. of Canada, 558 F.3d
440, 446 (6th Cir. 2009) (“Even though [the administrator]
did not have the opinion accompanying the notice of award,
it still was well aware of the uniform federal standard that
applies to Social Security claims.”).
Ordinarily, a proper acknowledgment of a contrary SSA
disability determination would entail comparing and contrast-
ing not just the definitions employed but also the medical evi-
dence upon which the decisionmakers relied. See, e.g.,
MetLife I, 461 F.3d at 668. Unfortunately, the administrative
record in this case only contains the SSA’s award letters with-
out the opinion by the SSA administrative law judge (ALJ) or
the SSA administrative record on which that decision was
based. This omission makes the process of comparing and
contrasting the two opposing disability determinations more
difficult.
Although the Plan places the burden on Montour to submit
“written proof” of his disability, that is, the pertinent docu-
ments and information necessary to facilitate a disability
determination, regulations promulgated by the Secretary of
Labor authorize, if not require, plan administrators working
with an apparently deficient administrative record to inform
claimants of the deficiency and to provide them with an
opportunity to resolve the problem by furnishing the missing
information. See 29 C.F.R. § 2560.503-1(f)(3)-(4), (g)(1)(iii);
see also Saffon, 522 F.3d at 870 (“In resolving [Montour]’s
claim for benefits, [Hartford] was required to give [him] ‘a
description of any additional material or information’ that was
‘necessary’ for [him] to ‘perfect the claim[.]’ . . .” (quoting 29
C.F.R. § 2560.503-1(g)(1)(iii) (alterations omitted))). We
have also construed this regulation to require a plan adminis-
trator denying benefits in the first instance to notify the claim-
ant not just of the opportunity for internal agency review of
that decision but also of what additional information would be
MONTOUR v. HARTFORD LIFE & ACCIDENT 15391
necessary “to perfect the claim[.]” Chuck v. Hewlett Packard
Co., 455 F.3d 1026, 1032 (9th Cir. 2006).
Although the record reflects that Montour kept Hartford
regularly apprised of his continuing disability status with the
SSA, Hartford’s initial decision in this case made no mention
of the contrary SSA disability determination and did not
advise Montour that further documentation, such as the ALJ’s
decision or the underlying administrative record, would facili-
tate Hartford’s review. At the appeals stage, Hartford’s sole
acknowledgment was that the SSA’s contrary determination
was “a consideration and part of the totality of the evi-
dence[,]” but it then continued with the statement that its deci-
sion “must be based on the weight of the evidence in this file
. . . .”
To the extent this latter statement implies that the missing
ALJ opinion and underlying record precluded Hartford from
attributing much weight to the SSA’s contrary determination,
this information came too late. See Chuck, 455 F.3d at 1032;
Saffon, 522 F.3d at 871 (“Insofar as [Hartford] believed that”
additional documentation establishing the reasoning and evi-
dence underlying the SSA’s disability determination “was
necessary for it to evaluate [Montour]’s claim,” it should have
said so “at a time when [Montour] had a fair chance to present
evidence on this point.”); see also 29 C.F.R. § 2560.503-
1(h)(2)(iv) (requiring plan administrators to consider docu-
mentation submitted by a claimant at the appeal stage). Mon-
tour does not challenge the reasonableness of Hartford’s
claims procedures on appeal. See 29 C.F.R. § 2560.503-
1(h)(2), (l). Nevertheless, we explained in Abatie that “an
administrator that adds, in its final decision, a new reason for
denial, a maneuver that has the effect of insulating the ratio-
nale from review, contravenes the purpose of ERISA[,]” and
“[t]his procedural violation must be weighed . . . in deciding
whether [the administrator] abused its discretion.” 458 F.3d at
974.
15392 MONTOUR v. HARTFORD LIFE & ACCIDENT
Ultimately, Hartford’s failure to explain why it reached a
different conclusion than the SSA is yet another factor to con-
sider in reviewing the administrator’s decision for abuse of
discretion, particularly where, as here, a plan administrator
operating with a conflict of interest requires a claimant to
apply and then benefits financially from the SSA’s disability
finding. See MetLife II, 128 S. Ct. at 2352 (“This course of
events [is] not only an important factor in its own right
(because it suggest[s] procedural unreasonableness), but also
would . . . justif[y] the court in giving more weight to the con-
flict (because [Hartford]’s seemingly inconsistent positions
were both financially advantageous).”).
[12] Weighing all of the foregoing factors together, we con-
clude that Hartford’s conflict of interest improperly motivated
its decision to terminate Montour’s benefits. This constituted
an abuse of its administrative discretion.
IV. Conclusion
[13] We reverse the district court’s summary judgment in
favor of Hartford and remand to the district court to enter
summary judgment in favor of Montour and to order the rein-
statement of long-term disability benefits in accordance with
this opinion and the terms of the Plan. See Pannebecker, 542
F.3d at 1221 (“[W]hether the administrator abused its discre-
tion because the decision was substantively arbitrary or capri-
cious, or because it failed to comply with required procedures,
benefits may still be reinstated if the claimant would have
continued receiving benefits absent the administrator’s arbi-
trary and capricious conduct.”).
REVERSED and REMANDED.