Yolanda Rios v. Unum Life Insurance Company ( 2021 )


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  •                            NOT FOR PUBLICATION                           FILED
    UNITED STATES COURT OF APPEALS                       DEC 27 2021
    MOLLY C. DWYER, CLERK
    U.S. COURT OF APPEALS
    FOR THE NINTH CIRCUIT
    YOLANDA RIOS,                                   No.    21-55020
    Plaintiff-Appellee,             D.C. No.
    2:19-cv-04100-DOC-SK
    v.
    UNUM LIFE INSURANCE COMPANY                     MEMORANDUM*
    OF AMERICA; PROVIDENT LIFE AND
    ACCIDENT INSURANCE COMPANY;
    ARNOLD AND PORTER KAYE
    SCHOLER, L.L.P WELFARE BENEFIT
    PLAN; INDIVIDUAL DISABILITY
    INCOME POLICY NO. 6754470,
    Defendants-Appellants.
    Appeal from the United States District Court
    for the Central District of California
    David O. Carter, District Judge, Presiding
    Argued and Submitted November 18, 2021
    Pasadena, California
    Before: BERZON and RAWLINSON, Circuit Judges, and KENNELLY,** District
    Judge.
    *
    This disposition is not appropriate for publication and is not precedent
    except as provided by Ninth Circuit Rule 36-3.
    **
    The Honorable Matthew F. Kennelly, United States District Judge for
    the Northern District of Illinois, sitting by designation.
    Plaintiff Yolanda Rios (“Rios”) submitted claims for benefits under two
    ERISA-governed disability insurance policies issued by defendants Unum Life
    Insurance Company and Provident Life and Accident Insurance Company
    (collectively, “Unum”). Both policies defined “disability,” for the first 24 months
    of payments, as an inability to perform the material and substantial duties of one’s
    “own occupation.” After the 24 months, the definition of “disability” changed to
    whether the claimant could perform the material and substantial duties of “any
    occupation” for which the claimant would be qualified. Unum initially granted
    Rios “own occupation” benefits, but later terminated her benefits on the ground
    that she could perform her occupation as a User Support Specialist. It never
    addressed her request for “any occupation” benefits. Applying de novo review, the
    district court concluded that Rios was entitled to both “own occupation” and “any
    occupation” benefits. We affirm in part, reverse in part, and remand for further
    proceedings.
    1. The district court did not clearly err in concluding that Rios is entitled to
    “own occupation” benefits. Ample evidence—including credible subjective
    reports of pain, lumbar x-rays, spinal and knee MRIs, diagnostic examinations, and
    a report provided by Rios’s specialist treating physician—indicated that Rios
    cannot sit for over four hours in an eight-hour workday. That limitation prevents
    Rios from performing the material and substantial duties of a User Support
    2
    Specialist, entitling her to “own occupation” benefits under both of Unum’s
    insurance policies. See Armani v. Nw. Mut. Life Ins. Co., 
    840 F.3d 1159
    , 1163–64
    (9th Cir. 2016).
    2. The district court clearly erred in concluding, on the present record and
    without further proceedings, that Rios is entitled to “any occupation” benefits.
    Aside from a fully favorable Social Security Administration (“SSA”) decision
    issued on July 17, 2020, no record materials submitted to either Unum or the
    district court spoke to Rios’s functionality on or after July 11, 2020, the date of the
    transition from “own occupation” to “any occupation” benefits. Although Rios’s
    condition is progressive and may not improve, there are viable treatment options
    for her condition that could result in improved functionality—including steroid
    injections and back surgery—that she had not yet undertaken when the record
    closed. Although Rios was not required by the insurance policies to undergo such
    treatments, the record did not disclose whether, on or before the transition date, she
    nevertheless elected to undergo such treatments and, if so, whether her
    functionality improved. That factor distinguishes this case from one in which the
    permanence of the disability is self-evident.
    Finally, an SSA Administrative Law Judge (“ALJ”) concluded six days after
    the transition date that Rios was disabled because “no jobs . . . exist in significant
    numbers in the national economy that” Rios could perform. The SSA decision
    3
    does not specifically address Rios’s functionality as of the transition date, as
    opposed to earlier, and was based only on pre-transition date evidence. SSA
    decisions are entitled to some degree of deference by ERISA plan administrators
    such that failure to distinguish a contrary SSA decision may qualify as a “failure to
    consider relevant evidence.” Montour v. Hartford Life & Accident Ins. Co.,
    
    588 F.3d 623
    , 635 (9th Cir. 2009). Here, although the ALJ’s projection that Rios
    was unable as of the transition date to perform any job that exists in significant
    numbers in the national economy is entitled to consideration, the SSA decision,
    given its limited evidentiary foundation, cannot fully cure the lack of evidentiary
    support for the district court’s “any occupation” determination.
    In light of the foregoing analysis, we direct the district court, on remand, to
    remand the case to Unum to allow it to determine Rios’s entitlement to “any
    occupation” benefits in the first instance. Costs on appeal are awarded to Rios.
    AFFIRMED IN PART, REVERSED IN PART, AND REMANDED.
    4
    

Document Info

Docket Number: 21-55020

Filed Date: 12/27/2021

Precedential Status: Non-Precedential

Modified Date: 12/27/2021