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9th Cir. – Premature Denial

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  • 9th Cir. – Premature Denial

    Here’s a new case out of the Ninth Circuit, Narciso Cuaresma, Jr. v. Farmers Group Disability Income Plan, et al.. This is a very brief unpublished opinion. The court rules that there are genuine issues of fact which warrant a remand to Liberty.

    A genuine issue of fact exists regarding whether Liberty improperly denied Cuaresma’s claim for long-term disability benefits before the full amount of time authorized under the Policy to submit materials had expired. Liberty, in all communications with Cuaresma, advised him that he had until either November 2, 2014, or November 3, 2014, to submit any materials that Cuaresma wanted to be considered as part of his claim for long-term disability benefits. Liberty denied Cuaresma’s claim prematurely on October 30, 2014.

    Liberty further indicated in its denial letter that Cuaresma’s medical records and treating physicians supported the conclusion that Cuaresma could perform full time work, 8 hours a day, 5 days a week. A genuine issue of fact exists regarding Liberty’s reliance on this determination in its denial letter. This sentence had been crossed out by Cuaresma’s treating physician and had been returned to the Liberty doctor conducting the review on October 28, 2014. Cuaresma’s treating physician replaced this determination with the following: “Pt has had recurrent angina in the past when he has returned to work.”

    A genuine issue of fact also remains regarding the specific deadline set by Liberty for the return of the claim forms. The Policy provides that proof of claim must be given to Liberty no later than thirty days after the end of the Elimination Period. Cuaresma worked until April, 22, 2014. The Elimination Period ended on October 22, 2014. Cuaresma’s proof of claim should have been due thirty days after October 22, 2014. This would have given Cuaresma until sometime in mid-to-late November to complete the claim forms, not November 2, 2014, or November 3, 2014, as Liberty repeatedly stated.
    While the fact pattern here is odd, I did find it interesting that the Ninth Circuit found that Liberty denied the claim prematurely. The opinion is attached below.
    Attached Files