Courts May Admit Additional Evidence in Review of ERISA Denials

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U.S. Court of Appeals for the Ninth Circuit

In Muniz v. Amec Const. Management, Inc., ___ F.3d ___, 2010 WL 4227877 (9th Cir. (Cal.) Oct. 27, 2010), the Ninth Circuit Court of Appeals held that when a court reviews a plan administrator's ERISA benefits denial decision under the de novo standard of review, the burden of proof is on the claimant. The Ninth Circuit also held that the court may consider evidence beyond the administrative record, especially when a claim involves complex medical questions or issues of medical expert credibility. Under that standard, the court held that Dierro Muniz, a man diagnosed with HIV, did not qualify for continued total disability benefits under his insurance plan.

Muniz was insured under a long-term disability insurance plan issued by Connecticut General Life Insurance Company (CGLIC), enabling him to continue to receive benefits after 24 months if he is "totally disabled," or "unable to perform all the essential duties of any occupation for which [he is] or may reasonably become qualified." Muniz had been receiving total disability benefits under the CGLIC plan due to the effects of his HIV infection from 1992 until 2005, when his claim was reviewed. After reviewing his claim and medical records, CGLIC determined that Muniz was not totally disabled. Muniz's treating physician disagreed with the decision and provided supplemental documentation, but CGLIC found that the records were incomplete.

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