United States District Court, D. Arizona
Honorable John J. Tuchi United States District Judge.
issue is Plaintiff's Motion to Admit Certain Non-Record
Documents (Doc. 78, Mot.). Defendant filed a Response in
Opposition to the motion (Doc. 80, Resp.).
is an employee of Sunstate Equipment Co., LLC (Sunstate).
(Doc. 1, Compl. ¶ 6.) Defendant is the medical insurance
provider for Sunstate employees, including Plaintiff. (Compl.
¶ 6.) After Defendant denied Plaintiff's claims for
coverage related to cancer treatment, Plaintiff filed an
action under the Employee Retirement Income Security Act
(“ERISA”). (Doc. 1, Compl.)
13, 2018, Plaintiff filed an Opening Brief (Doc. 77, Pl. OB)
and a Motion for Admission of Documents (Mot.). Plaintiff
seeks to admit the following: Blue Cross Blue Shield of
Arizona's (“BCBSAZ”) Appeal Guidelines and
Procedures manual (Doc. 77-1); discovery responses served on
Plaintiff (Docs. 77-2 and 77-3); proof of payment by
Plaintiff of the cost of treatment for which he seeks
recovery of benefits (Doc. 77-4); two public website
materials posted by Harvard Pilgrim Health Care and Health
Care Service Corporation (Docs. 77-5 and 77-6); and all
documents produced by Defendant in response to discovery
requests. (Mot.) In response, Defendant objects only to
admission of the BCBSAZ Appeal Guidelines and Procedures
manual (Doc. 77-1) and the materials from the public websites
of Harvard Pilgrim and Health Care Service Corporation (Docs.
77-5 and 77-6). (Resp.)
ERISA cases, whether evidence outside the administrative
record may be admitted depends on the whether the court
reviews the benefits decision under an abuse of discretion or
de novo standard. See Abatie v. Alta Health & Life
Ins. Co., 458 F.3d 955 (9th Cir. 2006). The Ninth
Circuit recognized that “in general, a district court
may review only the administrative record when considering
whether the plan administrator abused its discretion, but may
admit additional evidence on de novo review.”
Id. at 970.
plan grants the administrator discretion in approving or
denying a claim, courts apply an abuse of discretion review
to the administrator's decision. Id. at 969. The
more lenient abuse of discretion standard is limited to the
evidence in the administrative record. Id. at 970
(“[I]n general, a district court may review only the
administrative record when considering whether the plan
administrator abused its discretion”). However, a
potential conflict of interest may be proven through evidence
outside the administrative record, as long as the evidence is
used to show “the nature, extent, and effect on the
decision-making process of any conflict of interest.”
Id. at 970. The most obvious conflict of interest
occurs when the plan administrator “both administers
the plan and funds it, ” therefore acting as both
administrator and fiduciary. Id. at 967. When that
is the case, the plaintiff “will have the benefit of an
abuse of discretion review that always considers the inherent
conflict . . . even in the absence of ‘smoking gun'
evidence of conflict.” Id. at 969. In any case
of potential conflict of interest, even when the
administrator is not a fiduciary but may have some other
conflict, the court may look outside the record to determine
whether such a conflict exists and ultimately “must
decide in each case how much or how little to credit the plan
administrator's reason for denying insurance
coverage.” Id. at 968. While this limited
exception allows extrinsic evidence under the abuse of
discretion standard when necessary to determine whether a
conflict of interest affected the administrator's
decision, “the decision on the merits, though, must
rest on the administrative record once the conflict (if any)
has been established.” Id.
other hand, when a plan confers no discretion on the
administrator, a court will review the decision de novo.
Id. at 969. Under this standard, the court is
permitted to examine evidence outside of the administrative
record. Id. at 970 (“While under an abuse of
discretion standard our review is limited to the record . . .
this limitation does not apply to de novo review.”)
(quoting Jebian v. Hewlett-Packard Co. Emp. Benefits Org.
Income Prot. Plan, 349 F.3d 1098, 1110 (9th Cir. 2003)).
Courts are not required to accept extrinsic evidence, and
should review it only “when circumstances clearly
establish that additional evidence is necessary to conduct an
adequate de novo review.” Jebian, 349 F.3d at
1110 (quoting Mongeluzo v. Baxter Travenol Long Term
Disability Benefit Plan, 46 F.3d 938, 944 (9th Cir.
default, the Ninth Circuit applies a de novo review, and in
order to trigger “the more lenient abuse of discretion,
the plan must unambiguously provide discretion to the
administrator.” Abatie, 458 F.3d at 963. In
deciding whether the plan administrator has discretion,
“[t]he essential first step of the analysis . . . is to
examine whether the terms of the ERISA plan unambiguously
grant discretion to the administrator.” Id.
While “[t]here are no ‘magic' words that
conjure up discretion . . . the Supreme Court has suggested
that a plan grants discretion if the administrator has the
‘power to construe disputed or doubtful terms' in
the plan.” Id. (quoting Firestone Tire
& Rubber Co. v. Bruch, 489 U.S. 101, 111 (1989)).
The Ninth Circuit has held that wording “granting the
power to the interpret plan terms and to make final benefits
determinations” is sufficient to confer discretion on
the administrator. Id. But plans “are
insufficient to confer discretionary authority on the
administrator when they do not grant any power to construe
the terms of the plan.” Id. at 964.
Plaintiff wishes to admit several documents outside of the
administrative record, only some of which are contested.
Defendant does not object to the admission of discovery
responses served on Plaintiff (Docs. 77-2 and 77-3), proof of
Plaintiff's payment for his medical treatment (Doc.
77-4), or documents produced in response to discovery
requests. (Resp.) Those documents are therefore admitted.
BCBSAZ's manual (Doc. 77-1) Defendant argues that the
manual Plaintiff seeks to admit is the 2017 version, which is
inapplicable to Plaintiff's 2014 claim. (Resp.) Defendant
also points out that the 2014 manual is currently part of the
administrative record. (Resp. at 1.) Indeed, Plaintiff cites
to the 2014 version throughout his Opening Brief (Pl. OB).
The Court finds no need to admit the 2017 manual when it has
no bearing on Plaintiff's case. Thus, Plaintiff's
motion is denied as to Doc. 77-1.
only remaining evidence which Plaintiff seeks to admit from
outside the administrative record are two public website
materials posted by Harvard Pilgrim Health Care and Health
Care Service Corporation. (Mot.) Specifically, these pages
describe the coverage that those two insurance companies
provide for Plaintiff's cancer treatment. (Resp. at 1.)
Presumably, Plaintiff seeks to admit them to show that other
insurers cover his treatment and that it was unreasonable for
Defendant not to. ...