Montour v. Hartford Life & Accident Ins. Co.

In Montour v. Hartford Life & Accident Ins. Co., 582 F.3d 933 (September 14, 2009), the Ninth Circuit determined that a conflict of interest heavily influenced the benefits decision and ruled for plaintiff. Specifically, the Court pointed to the administrator’s bias in advocating its position that the claimant was not disabled, its reliance on surveillance that was consistent with the claimant’s self-reported limitations, and its decision not to seek an independent medical examination and instead rely on “paper reviews” when it was not clear that the medical reviewers had all the pertinent information. Going further, the Ninth Circuit took umbrage with the administrator’s failure to explain why it reached a different conclusion than the Social Security Administration, given that the administrator required the claimant to apply for benefits and would benefit financially from the award.

The Ninth Circuit upheld the one-year limitations provision in a summary plan description (SPD), finding that the SPD limitations period clause which was placed in the Claims Procedure section of the SPD complied with ERISA regulations and (assuming, without ruling that the Doctrine of Reasonable Expectations applied to a self funded ERISA plan, met the plan participants’ reasonable expectations.