The Ninth Circuit Court of Appeals found that CIGNA‘S decision to deny disability benefits to a claimant with chronic fatigue was illogical, implausible and without support because:
- Every doctor who personally examined the insured concluded that he was disabled;
- The Plan Administrator demanded objective tests to establish the existence of a condition for which there are no objective tests;
- The Administrator failed to consider the Social Security Disability Award;
- The reasons for denial shifted as they were refuted, were largely unsupported by the medical file, and only the denial stayed constant;
- The Plan Administrator failed to engage in the required “meaningful dialogue.”
The Court confirmed that in disability claims that turn upon subjective evidence such as the amount of a claimant’s pain and fatigue, it is an abuse of discretion for the insurer to rely upon doctors who merely review the records without examining the patient when there is a uniformity of agreement by treating physicians that the individual is disabled.
Another important feature of the case was the Ninth Circuit confirming that an ERISA Plan physician’s report is one of the documents that the Plan is required to provide the claimant as part of its duty to provide a full and fair review. Most importantly, the Court held that these physicians’ reports must be provided prior to a final determination. This allows the claimant to comment on or rebut the Plan’s physician’s report.