Prichard v. Metropolitan Life Insurance
783 F.3d 1166
| 9th Cir. | 2015Background
- Prichard is IBM employee covered by IBM's Long-Term Disability Plan insured/ administered by MetLife.
- MetLife approved psychiatric disability with retroactive start date of July 20, 2006 but capped benefits at 24 months for mental/nervous disorders.
- In May 2008 MetLife notified that benefits would expire; invited evidence for continuing benefits beyond June 2008.
- MetLife terminated benefits on July 12, 2008 after reviewing updated medical records; Prichard appealed unsuccessfully.
- District court and parties debated the proper standard of review under ERISA; SPD allegedly granted discretionary authority to MetLife.
- This appeal holds that the district court should review MetLife’s denial de novo, not for abuse of discretion, and remands for de novo review.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Standard of review for denial of benefits | Prichard; district court should apply de novo review. | MetLife; SPD grants discretion; abuse of discretion governs. | De novo review required; vacate and remand. |
| SPD vs plan document as controlling instrument | Amara limits SPD enforceability as plan terms; SPD cannot prevail if not part of plan. | SPD and Plan are effectively one document; SPD grants discretion. | SPD is not the sole plan document here; insurance certificate contains the plan terms; remand for de novo review. |
Key Cases Cited
- Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101 (1989) (establishes standard of review framework for ERISA benefit denials)
- Abatie v. Alta Health & Life Ins. Co., 458 F.3d 955 (9th Cir. 2006) (requires de novo review of standard choice, with factual review for clear error)
- Amara v. CIGNA Corp., 131 S. Ct. 1866 (2011) (SPD terms not themselves the plan terms; limits on altering plan terms via summaries)
- Grosz-Salomon v. Paul Revere Life Ins. Co., 237 F.3d 1154 (9th Cir. 2001) (integration clause limits reliance on extraneous documents for discretionary terms)
- Thomas v. Oregon Fruit Prods. Co., 228 F.3d 991 (9th Cir. 2000) (burden on plan to prove discretionary authority exists)