Ninth Circuit Vacates Denial of ERISA Benefits, Faults Procedural Deficiencies in UnitedHealthcare’s Claims Process

In Solis v. T-Mobile US, Inc., et al., No. 24-2412, 2025 WL 1937089 (9th Cir. July 15, 2025), the Ninth Circuit vacated a district court ruling that upheld the denial of medical benefit claims under an employer-sponsored ERISA plan. The court found that UnitedHealthcare (“United”), acting as the plan administrator, failed to provide the plaintiffs with the required level of explanation for its denials—violating ERISA’s procedural safeguards and denying them a fair opportunity to respond.

The plaintiffs underwent hiatal hernia repairs during the same surgeries as their gastric sleeve procedures. United denied coverage for the hernia repairs, stating only that the procedures were “not supported” and “may be considered included” under other billing codes. United repeated these explanations verbatim in the administrative appeal denial without citing any specific plan provisions or reimbursement guidelines. The Ninth Circuit held that such vague and conclusory denials fell short of ERISA’s requirement that plan administrators provide “specific reasons” and cite the “specific plan provisions” forming the basis of the denial. This failure rendered United’s administrative process procedurally defective under 29 U.S.C. § 1133 and 29 C.F.R. § 2560.503-1.

Although the district court acknowledged United’s deficient explanations, it declined to allow plaintiffs to supplement the administrative record. The Ninth Circuit found this to be legal error, citing Abatie v. Alta Health & Life Ins. Co., 458 F.3d 955 (9th Cir. 2006), which holds that courts must permit record augmentation when procedural irregularities have tainted the administrative process. Plaintiffs had attempted to supplement the record both pre-trial and post-trial with declarations that directly addressed United’s newly articulated denial rationales—such as the location of incisions and the surgical techniques used—but the district court refused to consider them.

Compounding the problem, United introduced new justifications during litigation that were never communicated to plaintiffs during the administrative process. The Ninth Circuit emphasized that under Harlick v. Blue Shield of California, 686 F.3d 699 (9th Cir. 2012), plan administrators cannot rely on post-hoc rationales to defend claim denials in court. Doing so deprives claimants of the opportunity to meaningfully respond during the administrative phase.

Ultimately, the Ninth Circuit vacated the judgment and remanded the case for further proceedings. The panel left it to the district court’s discretion to either allow further factual development and retry the case or remand it to United for reconsideration of the claims following proper administrative procedures.

This case is a powerful reminder that ERISA plan administrators must strictly comply with procedural requirements when denying benefits. Failure to cite specific plan terms and offer meaningful explanations during the claims process can result in the invalidation of claim denials—even when the plan grants discretionary authority to the administrator. Moreover, courts must remedy such procedural errors by permitting claimants to augment the record and present additional evidence when necessary. The decision reinforces ERISA’s purpose: to ensure fairness, transparency, and accountability in the adjudication of benefit claims.