Ordorf v. Paul Revere Life Insurance Company, 404 F.3d 510 (1st Cir. 2005)

When the Plaintiff Has the Burden To Present Proof in Support of Their Claim

Plaintiff appealed the district court’s denial of benefits on de novo review of an ‘own occupation’ disability policy.  He started benefits in 1995 for drug dependency but was limited to three years of benefits for that condition.  Before benefits ended for that reason he informed the defendant he was disabled due to back problems.  Plaintiff treated for back injuries beginning in 1976.  He did have objective evidence of disc disease and had multiple treatments over the years.  The question for the first circuit was what is entailed in a de novo review. Firestone v. Bruch, 489 U.S. 101 (1989) makes clear that in plain language disputes, no deference is given and courts should apply the normal rules for contract interpretation.  But it also includes a conclusion to deny benefits based on a set of facts.  The court agreed with the plaintiff that the correct standard is whether, upon a full review of the administrative record, the decision of the administrator was correct.  De novo review generally consists of the court’s independent weighing of the facts and opinions in the record to determine whether the claimant has met his burden of showing that he is disabled within the meaning of the policy.  Plaintiff bears the burden of making a showing sufficient to establish a violation of ERISA.  GRE Ins. Group v. Met. Boston Hous., 61 F.3d 79, 81 (1st Cir. 1995).  As in deferential review, see Liston v. Unum, 330 F.3d 19 (1st Cir. 2003) on de novo review, the focus of judicial review is ordinarily the record made before the administrator and at least some very good reason is needed to overcome that preference.  After an exhaustive review of the medical history and other facts, the court concluded that Plaintiff did not meet his burden because he worked for years despite back pain and treatment, he originally became disabled for drug dependency, his back pain was controllable even after he went out on disability, his recreational life was inconsistent with his claim, the SSA decision did not establish disability due to back problems alone and his claim based on the back disability came only after he expressed concerns with work issues as he started to cope with the idea of getting cut off from benefits based on the drug disability limitation. 

 

Other notable rules and statements:

The plan is limited to the grounds of denial it articulates to the claimant.  Citing Glista v. Unum Life Ins. Co., 378 F.3d 113, 128-29 (1st Cir. 2004).  (It’s hard to see how this applies to de novo review).  Summary judgment is just a vehicle for deciding the issue Liston v. Unum, 330 F.3d 19 (1st Cir. 2003).  The fact that judicial review is de novo does not itself entitle a claimant to a trial or to put on new evidence.

 

The Takeaway: The Plaintiff received benefits for 3 years for the reason of drug dependency. When the benefits were to run out, he also claimed disability due to back problems dating back to an injury sustained in 1976. The Plaintiff needed to show that the defendant violated ERISA and thus, resulted in no extension of disability benefits for the Plaintiff. The court ruled that the Plaintiff did not meet the requirements to receive benefits related to his back problems since he has been working since said back injury, and the claim was only brought up due to “drug dependency” benefits that were set to expire.

Ordorf v. Paul Revere Life Insurance Company, 404 F.3d 510 (1st Cir. 2005)

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