NOT FOR PUBLICATION FILED
UNITED STATES COURT OF APPEALS MAY 31 2018
MOLLY C. DWYER, CLERK
U.S. COURT OF APPEALS
FOR THE NINTH CIRCUIT
NARCISO CUARESMA, Jr., No. 16-16946
Plaintiff-Appellant, D.C. No.
2:15-cv-02192-JAM-EFB
v.
FARMERS GROUP DISABILITY MEMORANDUM*
INCOME PLAN, an ERISA Plan and
LIBERTY LIFE ASSURANCE COMPANY
OF BOSTON,
Defendants-Appellees.
Appeal from the United States District Court
for the Eastern District of California
John A. Mendez, District Judge, Presiding
Argued and Submitted April 12, 2018
San Francisco, California
Before: W. FLETCHER and TALLMAN, Circuit Judges, and MORRIS,** District
Judge.
Narciso Cuaresma, Jr. appeals the district court’s order granting summary
judgment for Farmers Group Disability Income Plan (“the Plan”) and Liberty Life
*
This disposition is not appropriate for publication and is not precedent
except as provided by Ninth Circuit Rule 36-3.
**
The Honorable Brian M. Morris, United States District Judge for the
District of Montana, sitting by designation.
Assurance Company of Boston (“Liberty”). We have jurisdiction under 28 U.S.C.
§ 1291, and we reverse and remand. Liberty will be required to process
Cuaresma’s claim properly and allow Cuaresma an appropriate length of time to
submit proof of his claim.
Cuaresma filed this action against Liberty and the Plan on October 21, 2015.
Cuaresma alleges that Liberty improperly denied his claim for long-term disability
benefits on October 30, 2014, before Liberty had received the claim forms that
constituted Cuaresma’s proof of claim. The complaint alleges that Cuaresma
submitted a timely, complete application for long-term disability benefits on
September 10, 2015. The district court erred when it granted Liberty’s motion for
summary judgment on their sixth affirmative defense that Cuaresma had failed to
exhaust his administrative remedies.
Liberty issued a Group Disability Income Policy (“the Policy”) to Farmers
Group, Inc. that insures long-term disability benefits under the Plan. Liberty
possesses the exclusive authority to decide and pay claims for long-term disability
benefits under the Policy. Liberty will pay monthly long-term disability benefits to
“Covered Persons” after they complete an “Elimination Period” of twenty-six
weeks.
The Covered Persons must provide proof of current “disability” no later than
thirty days after the end of the Elimination Period. To be “disabled” for purposes
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of long-term disability benefits, the claimant must show that he or she “is unable to
perform all of the material and substantial duties of his occupation on an Active
Employment basis because of an Injury of Sickness.” Liberty possesses no
obligation to pay a monthly benefit after the end of the Elimination Period unless it
“receives proof that a Covered Person is Disabled due to Injury or Sickness and
requires the regular attendance of a Physician.”
Liberty wrote to Cuaresma on September 19, 2014, to advise him that
Liberty would begin reviewing his claims for long-term disability benefits.
Cuaresma had not yet made any claim for those benefits. Liberty advised that the
twenty-six weeks provided for short-term disability benefits would end on October
21, 2014.
Liberty’s letter included six forms to be completed and returned by
Cuaresma. Liberty informed Cuaresma that the Policy required him to return the
enclosed claim forms and any remaining medical records by November 2, 2014.
Liberty sent various other letters and telephone reminders to Cuaresma
requesting the claim forms and medical records by November 3, 2014. Liberty
decided Cuaresma’s long-term disability claim on October 30, 2014, before having
received the claim forms and before either of the dates that Liberty stated that they
would make the determination. Liberty determined that Cuaresma did not qualify
as “disabled” based on the totality of the medical and vocational evidence.
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Liberty’s denial letter stated that Cuaresma’s medical records and treating
physicians support “full time work, 8 hours a day 5 days a week.”
Liberty advised Cuaresma of his right to request a review and that he was
required to request such review within 180 days of having received the denial
letter. Cuaresma did not appeal the denial. Liberty received a letter from Cuaresma
on September 15, 2015. This letter included Cuaresma’s completed application for
long-term disability benefits. Cuaresma claimed that “Liberty Mutual issued a
decision on [his] long term disability claim without receiving his required long
term disability proof of claim.”
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
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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.
Genuine issues of fact remain regarding whether Liberty properly handled
and denied Cuaresma’s long-term disability benefits claim. We reverse and remand
with instructions to the district court to remand this case to Liberty to fully
evaluate the merits of Cuaresma’s claim in compliance with the Policy. See Demer
v. IBM Corp. LTD Plan, 835 F.3d 893, 907 (9th Cir. 2016).
Appellees shall bear the costs of appeal. See Fed. R. App. P. 39(a)(3).
REVERSED AND REMANDED.
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