Muniz v. Amec Construction Management, Inc., 623 F.3d 1290

Muniz is insured under a CGLIC long-term disability plan governed by ERISA; benefits extend after 24 months if totally disabled.
Muniz was diagnosed with HIV in 1989 and stopped work in 1991; he began receiving total disability benefits in 1992.
In 2005 a routine claim review led to consideration of his fatigue, respiratory symptoms, and concentration issues based on forms and his doctor’s notes.
CGLIC’s vocational assessment concluded Muniz could perform sedentary clerical work; a nurse case manager found the medical records did not support severe symptoms.
Dr. Towner, Muniz’s treating physician, opined Muniz would be unable to work in any field in the foreseeable future, but his records were incomplete and not consistently supportive.
The plan administrator suspended benefits in 2006 for failure to complete a Functional Capacity Evaluation (FCE); Muniz disputed via administrative appeals and then ERISA litigation; the district court ordered an independent FCE in 2009, and ultimately affirmed termination of benefits in favor of the plan.

Issue	Plaintiff's Argument	Defendant's Argument	Held
Who bears the burden of proof in de novo ERISA review	Muniz argues the administrator should bear the burden after初 evidence of disability	Muniz (as plaintiff) bears burden under de novo review when plan grants no discretion	Burden stays on the claimant
Whether the district court properly admitted additional evidence via the 2009 FCE	Muniz contends extra evidence was improper for 2006 review	Court may admit additional evidence to conduct adequate de novo review	Court did not abuse discretion; FCE considered as supplementary evidence
Weight given to treating physician’s opinion (Dr. Towner)	Towner’s opinion supports total disability	Opinion was inconsistent and not adequately documented	Not controlling; not sufficient to prove total disability
Relevance of the 2009 FCE to 2006 disability determination	2009 results should establish disability status for 2006	FCE is a snapshot; not dispositive for 2006	Permissible as contextual evidence; not sole basis
Whether Muniz received a full and fair review under ERISA 1133	Muniz lacked opportunity to challenge FCE; inadequate process	Court provided opportunity and clarified order for FCE	Review deemed adequate; not reversible on this ground

Abatie v. Alta Health & Life Ins. Co., 458 F.3d 955 (9th Cir. 2006) (standard for de novo ERISA review when no discretion given to administrator)
Walker v. American Home Shield Long Term Disability Plan, 180 F.3d 1065 (9th Cir. 1999) (authority to consider independent expert in de novo review)
Metro. Life Ins. Co. v. Glenn, 554 U.S. 105 (U.S. 2008) (conflict of interest as a factor in abuse-of-discretion review)
Lang v. Long-Term Disability Plan of Sponsor Applied Remote Tech., Inc., 125 F.3d 794 (9th Cir. 1997) (abuse-of-discretion review; deference may be removed if tainted)
Saffon v. Wells Fargo & Co. Long Term Disability Plan, 522 F.3d 863 (9th Cir. 2008) (requires meaningful dialogue before final denial)
McOsker v. Paul Revere Life Insurance Co., 279 F.3d 586 (8th Cir. 2002) (previous payments do not estop later review; burden not shifted)
Gunderson v. W.R. Grace & Co. Long Term Disability Income Plan, 874 F.2d 496 (8th Cir. 1989) (burden remains with claimant; prior payments are contextual)
Connors v. Connecticut General Life Insurance Co., 272 F.3d 127 (2d Cir. 2001) (context on denials and initial disability determinations)
Opeta v. Nw. Airlines Pension Plan for Contract Employees, 484 F.3d 1211 (9th Cir. 2007) (recognizes need for expert consideration in complex medical questions)