recent case in which the district court went well beyond its proper role in performing judicial review of a claim determination under the abuse of discretion standard applying and incorrect definition of that standard and  evidence as if it was making the decision on its own for the st time that's not what it was a call for and that's why i will ask you to reverse this morning i feel compelled to begin with  what i think is the most obvious error in the district court's decision which is its use of a sufficient evidence to test in lieu of the proper substantial evidence test and i saw that in the orator and i thought well you know there maybe there's just a typo just got the word wrong it's not some antics and you could tell that from the content of the order and i think because it really made a difference in how the district court approached the its review on this case and i think the best example is is this five question health screening form that mr menorahs completed it's in the record of the human resource a for ford found it sent a copy to metlife said here it is this is the form here are the answers that mr menorahs gave to the questions and met life said great except that that as true and made its claim decision on the basis of that information this court disagreed and said said things that suggested the imposition of the burden of proof upon met life somehow independent  simply a review of the record that simply is not appropriate under a recess the district court's order said things like met life has not shown that the deceiving answered no to the questions met life has not proved that mr menorahs cancer is health related questions untruthfully metlife had no burden to prove authenticity of underlying documents in front of the district court in this matter in at this stage arista cases under the abuse of discretion standard of review simply is not a fact finding exercise and that's really what what judge battalion did in his review of this case it was  not just to use the wrong word but it was error to impose a burden of proving something more than simply the proper standard her view which is that the record contain more than a scintilla but less than a preponderance of evidence in support of the claim determination that metlife made and when when the plants you know designee for processing this life insurance underwriting information tells metlife here's the questions here are the answers meant life is entitle to rely upon that and that is sufficient proof in the record to satisfy the substantial evidence test that the district court sh nd i think the big picture item i want to emphasize this morning is is that it's a completely appropriate exercise for a benefit plan like for hiring an insurance company like metlife to choose to say that we're not going to allow employees to obtain optional life coverage unless and until the proper medical information is received by and then evaluated by and then approved by the insurance to establish that the employee is a suitable candidate for additional life insurance from a medical perspective remember this plan has a basic life component and an optional life component the basic life component is not underwritten it's a relatively modest benefit is fifty thousand dollars that was paid to misdemeanors a spouse in this instance but the structure of the plan allows the employee an opportunity for it for the employees can mean is to buy more insurance just like going to insure insurance agent buying more insurance so is there an additional premium to be paid for the optional life coverage yes and it's paid by employee withdrawn from their paycheck but to to structure your plan such that that coverage can't be issued and tell you employed demonstrate to us that you're medically suitable for  this coverage is an appropriate goal of interests a plan judge battalion in this order said it's said my understanding of the goal of this plan is to provide life insurance to people well we would characterize it a little bit differently certainly that's the goal of the basic life benefit the optional life benefits goal is to give the employees an opportunity to buy more coverage if and only if they can st establish medical eligibility for that coverage was to david to you i understand you're suggesting that we send this case back for another trial with the proper burden used is that where you're coming from here no your honor is that you are standard review as do novo in terms of you conduct your own evaluation as to whether the standard of review is satisfied our request is that you complete the system that review apply the abuse of discretion standard in the proper way and find that the claim determination was not an abuse of discretion and and and reverse and complete complete that task yourself that doesn't need to go back to judge battalion again you're  address then what is the substantial evidence in the record that you think supports the it isn't i mean sufficient evidence is in the standard is just a way could be just a way of referring to the standard if substantial it's not substantial it's and treatment for high blood pressure including hospital visits where he thought he was having a heart attack regular physician visits where he would run out of medication and have to go back to his doctors and ask for more and when  he st became eligible for this coverage he was asked a series of screening questions in order to trigger a more comprehensive underwriting process one of those questions was do you have any history of high blood pressure treatment for high blood pressure he said no because he said no that underwriting process never occurred it was never triggered by the health screening questions and without it met life was unable to evaluate in the st instance whether this candidate for optional life insurance was medically qualified to receive it or not and the way the plan is structured coverage never exists it's never issued in the st place unless and until that medical underwriting process takes the structure of this plan b and the record is clear the met life underwriter said from what i have in front of me i can't tell if we would have issued coverage or not but the way the way the plan was set up is to require that the underwriting process itself occur as the prerequisite to the issuance of coverage not that it be not that the outcome go one way or another and it's because of this multiple step process  in enroll that it starts with the screening questions and the screening questions are what triggers the more comprehensive medical evaluation so when an employee says no to everything the coverage issues met life's underwriting group never does anything and the coverage goes in place but when you get the yes answer that's what causes metlife to require a statement of health potentially review of medical records potentially have the person examined so that it's not taking an unreasonable risk in issuing coverage in the st instance but suppose they find out later one of the answers was wrong can the do they reconstruct what would have happened and say this wouldn't made any difference that's not what happens under the structure of this plan because as i say once you automatically cancel any policy when they find one they find that underwriting should have happened and didn't that's the event that causes the coverage to never go into into place that that they automatically cancel whenever there's an incorrect answer to one of the five screening questions or is the record that now sometimes they leave the policy in place if they decide that it was immaterial i'm not you know i don't know that this record goes into answer to the screening questions that's what triggers the additional underwriting process right now i understand beyond that i don't think the record speaks to the question about what happens when the company finds out later  answer we know what in this case what the what the letter the decision letter said was we didn't get to underwrite your file so your coverage never came to be going to judge sheppard might have a question just a quick one when the decision was made to deny the claim was there any provision made for refund of premiums yes the the initial letter said we will refund your premiums when your appeals are complete and you know as we sit here today obviously that the answer to coverage is still unknown metlife will refund the seventy one dollars and some sense and premium if and when it's determined that it's not very well thank you for your argument plan ford was the plan sponsor and the plan administrator that life was to claim administrator and the insurer in this instance for delegated to metlife the underwriting of the program the claim the terminations and the rodriguez had a viable claim for benefits under five a to a one b then she should not have been permitted to seek summary judgment or even get judgment on the three claims for equitable relief though should have been immediately dismissed it's hornbook law that you cannot both pursue an equitable claim under a three and a benefits claim under a one b in this instance the district court st found that there were to impose penalties in this situation for the record was undisputed that it was an inadvertent air the employee who received the st letter requesting the summary plan description quit ford's employment the letter was was does the statute for bad penalties in the case of negligence by the by the defendant no sir doesn't it does not the so inadvertence isn't really  discretion should have been exercised properly and in this case the court found that that ford's mistake was inexcusable but then later found that ford did not act maliciously or intentionally or in bad faith so we immediately sent a letter and we called the attorney and said we're sending the letter and the letter was and are sent the summary plan description and the attorney received the summary plan description before he filed suit saying he didn't get it  he had it for for at least two weeks before he sued us under under fifty to see saying the court order us to send it and what how should this direct yes i mean where in deciding what are you arguing that we need to do to rectify these problems that you just outlined we believe that the sanctions should be removed that we should put forward should not have been sanctioned for  handled by metlife and you seem to be saying we should say state or rule that if the failure was inadvertent and caused no prejudice then it's an obese or discretion to impose the penalty would that be the opinion you do not preclude the imposition of penalty so how could we right the opinion that says the opposite because no because the star case also says that the court should primarily look at whether or not the defendant acted intentionally maliciously on bad faith or whether there was prejudice and whether there was practice to the plaintiff and in this case she she had the summary plan description well before she filed so she didn't go back and try and reopen the administrative record to have it read determined she her attorney waited three months after filing suit to bring the benefits claim there's nothing that ford's one thousand dollars day delay did to prevent her from from seeking benefits in this case how much were the penalties originally twenty thousand dollars reduced to which was the maximum two thousand dollars penalty against ford  all right well thank you for your argument let's see mr monahan we'll hear from you made the applications to four ended up getting fired because he couldn't get the documents that he needed from forty spent a lot of time asking life for it i think there are at least five letters that you can find in the in the record if you look at the record and it cost my client a great deal of an attorney's fees actually more than what the penalty would be from ford motor company so the court did find well he asked the that ford out of pay what the statute requires that's all i'm saying but when it comes to prejudice that what was the prejudice of the nineteen days well when we st get the case we don't have it because it's with the other lawyer we finally get it there is of we believe that there was a period of time that we had to file the lawsuit and get going and one it was difficult to determine which met life to or were they actively involved in it and as you can see from the initial complaint we had it wrong we had to do and in many complaints there was some effort that we had to go through and besides the statutes are pretty clear it doesn't say there has to be malice or  anything else and the court did find that there was some prejudice to us in that we didn't receive it on time appropriately courts give great deference in these types of cases to the employer and i think the judge giant did give great deference but when he started looking at the record and they went through the record very carefully it was very confusing and it was contradictory there are all sorts of statements within the record indicating that we're not sure whether the five questions one were required to where they answered do we know exactly what their questions were do we know what the answers were do we know whether it's the same as the paper a very visual version or is it the computer version and i and i don't believe that they haven't really figured  that out certainly they found against the issuance of the insurance and then there were the number of questions so far let's assume he did answer them wrong with they still have granted the insurance and there 's a great deal of conversation and if you go through judge which i an opinion he sets it all out as to the confusion of what was going on and the statements were well we don't know we don't think that one that the plan requires this type of questions or or the or the some statement of the insurance requires it it was confusing back and forth but in the end the company said the plan does require the five questions and we have received what we believe are answers that the man gave one of which was not true that's right the company did make a decision so  that something that passes muster under an abuse of discretion well substantial evidence standard i think the standard is the court will give a great deal of deference to the decisions made and unless it's absolutely wrong and in this instance it was wrong and the court found that it was wrong i believe that they made the decision to deny insurance before they even knew whether it completely answered the questions whether that had been resolved  certainly it hadn't been resolved whether or not they would in fact having ensure you know thirty issue is that they had yearly updates for it had yearly updates and ford even filed a  affidavit one of their employees file an affidavit in and one of the briefs and on summary judgment saying that well that has nothing to do with it and ford wouldn't have met life wouldn't have any information regarding this instance because it wouldn't it wouldn't have applied except it was in the record metlife did have it it was there and it showed that his conditions in the subsequent years of medical exams were would show would have shown that his answers are no if he answered it no in fact accurate so that you know that's what i would judge which i it was faced with was if you simply gave them absolute deference which i don't believe the court has the right or obligation to do so then you but if you did that then you'd find for a metropolitan but that's not the court's job and the court's job in this instance was to take a look at it and see if it did pass muster and court and judge equitable rights to fashion a result of some kind with all these problems that both of both sides of set forth that's correct again i don't have as much faith in that and i'm not arguing that what i'm saying is that what judge which i and did is what the district courts are obligated to do which is to give great deference to the court but if the employer has it wrong and if you read the back and forth between the  underwriters and the business folks and and remember there is the issue of a conflict of interest when a company like metlife does both makes the determination and page the money out there is that and conflict a bit of interest but nevertheless all you have to do is read back and forth between all these people they didn't know what was going on and they nevertheless found a way to say  we're not going to give him insurance we're not going to grant it and we're going to pay it back when this case is over i would say that if you spend the time and money judgment times decision there is no way that you can reverse when you say you don't have much faith in the equitable claims you're not arguing it do you mean you don't argue this i could claim against ford that was discussed here briefly you're focused only on the claiming it's met life and i'm  focused on the claim against metlife forward always the two thousand dollars but you know penalties but the other claims against four do you agree those if we could have figured out a way to get forward out of this case without completely getting them out and causing problems for the court and the surgeon we might have done that well more than was just trying to nail down whether you are defending a judgment against ford other than the on the penalties you is there anything else you want to say about the met life claim or have you covered as i say i mean you if you look you look at the statements and the court and he has said some out verbatim from the record you'll see that this case was decided properly what about this point that it's improper improper to speculate about hypothetically what the company would have done if well that's what they were doing it answered the question this company company was making those decisions and they're saying that if you answer them wrong well they don't know really whether they're answering them wrong because they look at the records from before where they say well of course he had high blood pressure or he had heart pain all that well those were related to other instances they went away there was an explanation for this is by the underwriters themselves saying that and then there were a number of records that provided indication that there was no coronary problems there were no high blood pressure problems for years afterwards so the question is which which records are you going to take the other thing is they had my client sign a release they went back years  on records that would normally not be a part of it but it still after all of that the underwriters said you know even if you did answer yes to all of these questions we did still probably given him if the plaintiff had said yes to all the questions they would have given him insurance anyway if my records like i mean the company says that's contrary to their policy which says you have to go through underwriting one from caitlin what page are you reading from i'm reading from page fourteen a judge would tie ins i thought you were reading you ever been diagnosed or treated by a physical of a sick for other health care provider does not show the drop downs only the next question which is diagnosed treated again it is there more to this form where the st question is a question mark  plain master asks where the reaction about chest pains but this form doesn't show that question the plan master doesn't state that we has to ask about hypertension but there questionnaire does so this is not a complete answer to all of this you need to read judge battalion's decision where he weaves it all together using exactly the words from the underwriters and and the records  as i say he gave deference to the court as he should have but found that there was not instance a scintilla of evidence and the and found in favor of the plaintiff on this  and we believe it's a legitimate decision all right well we have the substantial record and we're in a position to reveal it so thank you for your argument thank you very lame shows the process by figuring out what happened and it was uncertain for a while but at the end of the day they figured out what questions were and what the answer was and were entitled to rely upon that deciding claim that's number one number two in that result and if that is true the result would be what in your view the result would be that this court would find that claim determination was not an abuse of discretion and dismissed case and so there'd please call the next case for argument