Ninth Circuit: An ERISA Administrator Cannot Rescue a Benefits Denial with a Plan Provision It Never Cited

In Roggenkamp v. Morgan Stanley Medical Plan, No. 24-7864, 2026 WL 1625357 (9th Cir. June 5, 2026), Plaintiff Roggenkamp sued the Morgan Stanley Medical Plan (“MS Plan”) under ERISA § 502(a), 29 U.S.C. § 1132(a), to recover benefits after Cigna, the plan’s administrator, denied his pre-authorization request for a two-level artificial disc replacement surgery (“two-level ADR”). Following a bench trial, the district court entered judgment for the MS Plan, and Plaintiff appealed. The Ninth Circuit affirmed in part, and reversed and remanded in part.

The court first affirmed the district court’s conclusion that Cigna did not operate under a conflict of interest. Because the parties agreed that the MS Plan granted Cigna discretionary authority, the abuse of discretion standard applied. A structural conflict arises only when an administrator both determines eligibility and pays for benefits. Here, Cigna adjudicated claims and determined eligible expenses while Morgan Stanley funded the plan, so Plaintiff could not establish a financial conflict. The court rejected Plaintiff’s contention that Cigna’s delays, its repeated conclusory denial language, and its interruption of his physician during a peer-to-peer call demonstrated a conflict, and it likewise rejected his argument that common law agency principles rendered Cigna’s conduct attributable to the MS Plan.

The court then reversed on the merits of the denial. ERISA requires that a denial notice state the specific reasons for the denial and reference the specific plan provisions on which the determination is based. In each denial letter, Cigna informed Plaintiff that it was denying coverage because there were “not enough studies” showing that two-level ADR is effective or improves health outcomes, citing only its internal Medical Coverage Policy No. 0104 (“MCP”), a non-plan document that categorically excludes two-level ADR as experimental. Cigna never relied on the Summary Plan Description (“SPD”), the undisputedly governing plan document, which defines “experimental, investigational or unproven” services but does not categorically exclude two-level ADR. In affirming the denial, the district court had interpreted the SPD’s definition and concluded that it was reasonable to classify two-level ADR as falling within it. The Ninth Circuit held that this was an improper post-hoc rationalization, because Cigna had relied only on the MCP during the administrative process, and the MCP and SPD are meaningfully different documents. A court may not affirm a denial on a rationale the administrator did not assert during the administrative process, as doing so deprives the claimant of the opportunity to respond and of the statutory right to full and fair review.

The court further held that Cigna abused its discretion in denying the claim. Cigna repeated verbatim the same brief statement in each denial letter, citing only the MCP’s categorical exclusion, and never referred to the SPD’s definition or explained how two-level ADR qualified under it. Cigna therefore did not interpret the governing plan document at all, much less reasonably, and it failed to engage in the meaningful dialogue ERISA requires by neglecting to address the information Plaintiff submitted in his appeals. The court reversed and remanded with directions to remand to Cigna for reevaluation of the merits under the SPD definition rather than the MCP definition. The parties were ordered to bear their own costs on appeal.