Ninth Circuit Orders Remand to Insurance Company to Decide Claimant’s Entitlement to “Any Occupation” Disability Benefits in the First Instance

Plaintiff Yolanda Rios had long-term disability benefit claims 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 have two definitions of disability. For the first 24 months, disability is defined as the inability to perform the material and substantial duties of one’s “own occupation.” After 24 months, one is disabled only if they cannot perform the material and substantial duties of “any occupation.” Unum denied Rios’s claims under the “own occupation” standard and never addressed her entitlement to “any occupation” benefits. On de novo review, the district court determined that Rios was entitled to benefits under both definitions of disability. In Rios v. Unum Life Insurance Company of America, et al., No. 21-55020, 2021 WL 6116635 (9th Cir. Dec. 27, 2021), the Ninth Circuit affirmed in part, reversed in part, and remanded for further proceedings.

The court found that the district court did not clearly err when it concluded that Rios was entitled to “own occupation” benefits because the decision was supported by 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” indicating that she cannot sit for over four hours in an eight-hour workday. However, the district court did clearly err in concluding that Rios is entitled to “any occupation” benefits because “[a]side 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.” Due to what the court considered to be viable treatment options for her condition, it found that this is not a case where the permanence of disability is self-evident. Even though the SSA concluded that Rios was disabled six days into the “any occupation” period of disability, the SSA decision did not specifically address Rio’s functionality as of the transition date from own occupation to any occupation disability. On remand, the district court is directed to remand the case to Unum to allow it to determine Rios’s entitlement to “any occupation” benefits in the first instance.