The Ninth Circuit Court of Appeals in Salomaa v. Honda LTD Plan 637 F.3d 958 found that CIGNA’s Insurance Company’s decision to deny disability benefits to a claimant with chronic fatigue syndrome 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 found that in a disability claim that turned upon subjective evidence, such as the amount of a claimant’s pain and fatigue, it was an abuse of discretion for the insurer to rely solely upon doctors who merely reviewed the records without examining the patient when there was a uniformity of agreement by treating physicians what the individual was disabled.
Another important feature of the case was the Ninth Circuit confirming that CIGNA’s physician 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 or his/her physician to comment on or rebut the insurer’s physician report prior to a final determination on appeal.