Retirement Board Abused Its Discretion in Disability Benefits Denial

By Morgan Lewis & Bockius LLP

Every month, the International Foundation releases the Legal and Legislative Reporter, a compilation of new employee benefits-related case summaries. Below is a summary we thought you’d be interested in:

The U.S. District Court for the Northern District of California grants the plaintiff former professional football player’s motion for summary judgment related to the denial of disability benefits.

The plaintiff is a former professional football player. The defendants include the retirement plan that provides disability benefits to eligible players and the retirement board that administers the benefits under the plan. The plan is governed by the Employee Retirement Income Security Act of 1974 (ERISA).

The plaintiff disputes the decision of the retirement board to deny him total and permanent disability benefits under the plan. The court previously found that the retirement board abused its discretion and inappropriately denied the plaintiff a full and fair review of his disability claim under ERISA. Upon appeal, the Ninth Circuit affirmed this court’s decision and remanded it for further proceedings. On remand, the plaintiff was allowed to provide additional evidence in support of his disability claim.

The plan provides that an individual qualifies for total and permanent disability benefits if they are substantially prevented from or substantially unable to engage in any occupation or employment for remuneration or profit and such condition is permanent. The plaintiff filed for total and permanent disability benefits based on injuries he suffered from years of playing professional football. The retirement board denied the plaintiff’s claim for disability benefits, finding that he was not totally and permanently disabled because (1) the neutral orthopedist found that he was employable and (2) he had not presented evidence that he received Social Security disability benefits. The plaintiff filed suit challenging the denial of disability benefits. Shortly after filing suit, the Social Security Administration (SSA) granted the plaintiff’s application for disability benefits and found that he has been disabled since October 1, 2012.

The court reviews the defendant retirement board’s decision for an abuse of discretion. First, the court notes that there is no question that the plan does not require objective medical evidence to support a disability claim. The court also notes that the opinion of the retirement board’s reviewing doctor was not persuasive and is illogical and implausible.

In addition, the court considers the SSA disability determination and finds that the plaintiff’s impairments could be reasonably expected to cause his debilitating pain and that the objective evidence of his impairments supported his allegations of pain. The court finds that the retirement board abused its discretion when it denied the plaintiff’s disability benefits and, after reviewing all the evidence, the plaintiff is under permanent and total disability and is entitled to benefits under the plan. While the court clarifies that ERISA plan administrators are not bound by SSA disability findings, complete disregard for a contrary conclusion without so much as an explanation raises questions about whether an adverse benefits determination was the product of a principled and deliberative reasoning process. The court also finds that the defendant retirement board’s reasons for rejecting the SSA findings are illogical and implausible.

Moreover, the court also notes that the defendant retirement board’s decision is owed little deference. In considering the degree of deference to which the plan is entitled, the court must consider the retirement board’s course of dealing with the plaintiff, which the court finds suggests an intent to deny the plaintiff disability benefits regardless of the evidence presented. In denying the plaintiff’s initial claim for benefits, the retirement board noted potentially conflicting medical evidence contained in the record, but it did not resolve the conflicts by examining the evidence or delving into the record before it. Instead, the retirement board simply adopted the opinions of its retained physicians by default. In so doing, the retirement board showed an unreasonable bias in favor of plan-selected physicians.

Further, the retirement board initially denied the plaintiff’s claim for disability benefits based on the fact that the plaintiff wasn’t yet awarded Social Security benefits; however, the retirement board did not change its opinion when those Social Security benefits were later granted. Upon review, the retirement board did not review the Social Security record or give any weight to the grant of benefits. Based on the foregoing, the court finds that the defendant retirement board abused its discretion in denying the plaintiff’s request for disability benefits.

Finally, the court also finds that the plaintiff’s pain clearly demonstrates total and permanent disability. Each of the plaintiff’s treating and examining physicians recorded his debilitating reports of pain. In fact, even the retirement board’s neutral examining physicians corroborated the plaintiff’s reports of severe pain. Consequently, the record shows that the plaintiff’s pain renders him substantially unable to engage in any occupation or employment for remuneration or profit on a permanent basis.

Accordingly, the court grants the plaintiff’s motion for summary judgment.

Content provided by Morgan, Lewis & Bockius LLP.

Dimry v. Bert Bell/Pete Rozelle NFL Player Retirement Plan et al., No. 19-cv-05360-JSC (N.D.Cal., June 1, 2022).

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