NOT FOR PUB LIC ATION UNITED STATES C OUR T OF APPEALS FOR THE NINTH C IR C U IT
M AR N IE M ASUDA-C L EVELAND, ) No. 17-17149 ) Pla intiff-Appe lla

nt, ) D.C . No. 1:16-c v-00057-LEK-R LP ) ) M EM OR

A NDUM * v. ) ) LIFE INSUR

ANC E C O M PANY OF ) NOR T H AM ER IC A, ) ) De fe nda nt-Appe lle e . ) )

Appe a l from

the Unite d

Stat e s Distric t C ourt for the Distric t of Ha

wa ii Le slie E . Koba

y a shi, Distric t Judge , Pre siding Subm itte d

April 16, 2019 ** San Fran c isc o , C a lifornia B e fore : D.W . NELSON, FER NANDEZ, a

nd B EA, C irc uit Judge s.
M arnie M a suda -C le ve la

nd a ppe a ls the distric t c ourt’ s gra nt of sum m ary 

# FIL ED
M AY08 2019 M OLLY C. DW Y ER, CLERK U

. S. CO URT O F APPEALS

* This disposition is not a

ppropria te for public ation a

nd is not pre c e de nt e xc e pt a s provide d

by 9th C ir. R . 36-3.

** T he pa ne l una nim ously finds this c a se suita

ble for de c ision without ora l argum e nt. Fe d. R . App. P. 34(a )(2).judgm e nt in fa vor of Life Insura

nc e C om pa ny of North Am e ric a

(“ LINA” ) in he r ER ISA 1 a c t ion to re c o ve r be n e fits unde r an a c c ide nt pla n (“ the Plan ” ) c re ate d by the e m ploy e r of he r husba

nd, Ha rlan M a suda , for the be n e fit of its e m ploy e e s. Se e 29 U.S.C . § 1132(a )(1)(B ). W e va c ate and re m and. M a suda -C le v e la

nd a sse rts tha

t the distric t c ourt e rre d be c a u se it did not give he r an opportunity

to submit a dditiona l e vide nc e to support her c la im for be ne fits
and be c a u se it de te rm ine d tha

t LINA did not ha

ve a substa

ntia l c onflic t of inte re st be y ond the struc tura l c onflic t it ha d a s both the Plan a dm inistra

tor a nd the pa y or of be ne fits unde r the Pla

n. W e a gre e . (1) The Pla

n p rovide d c ove ra g e for de at h from injurie s tha

t we re “ c a use d by an a c c ide nt” and “ from

no othe r c a

use s .” Through m ost of thea dm inistra tive proc e s s re ga

rding the be n e fit c la im , LINA e sse n tia l ly a g re e d tha

t Ha rlan M a suda ’ s de ath wa s c a

use d by the injurie s he re c e ive d in the a c c ide nt, but a sse rte d tha t a
m e dic a l e ve nt c a

use d the a c c ide nt itse lf. 2 Howe v e r, in LINA’ s ultim ate de c ision,

1 Em ploy e e R e t ire m e nt Inc om e Se c urity Ac t of 1974, Pub. L. No. 93–406, 88 Sta t. 829 (c o d ifie d a s a

m e nde d in sc atte re d se c tions of 26 &29 U.S.C
. ) (he re ina fte r, “ ER ISA” ).

2 W e note tha

t the phy sic ia

n fore nsic -pat

hologist who c om

ple t e d a n a utopsy wa s sa tisfie d tha t his de ath wa s, inde e d , c a use d by the a c c ide nt, a lthough she spe c ulate d tha

t he m ight ha

ve suffe re d “ an a c ute m e dic a l e ve nt” that le d to the a c c ide nt. 2whic h le d

to this re vie w, it c ha

nge d its position a

nd de c la re d tha t the de ath wa s not
c a use d by the injurie s he re c e ive d in the a c c ide nt, but wa s c a use d by the m e dic a l
e ve nt itse lf. In so doing, it re lie d upon a re p ort from

a diffe re n t phy sic ia

n fore nsic
pathologist tha

t ha d not be e n

pre viously disc l ose d. LINA a lso re fuse d to c onside r
any ne we vide nc e to re b ut the c onc lusions in tha t re port. Eve n

if a ll furthe r re vie w
wa s fore c lose d at LINA’ s le ve l , 3 LINA’ s ne w rationa le for de ny ing be ne fits substa ntia lly bolste re d its de nia l position. 4 The distric t c ourt should ha ve a llowe d M a s uda -C le v e la

nd to submi t, a

nd should ha

ve c onside re d , re butting e v ide nc e . 5 The c ourt’ s fa ilure to do so of ne c e ssity a ffe c te d its de c ision tha

t LINA ha d no
m ore tha n a struc tura l c onflic t of inte re st. Thus, the distric t c ourt e rre d. (2) Whe n a

distric t c ourt re vie ws a

n a d m i nistra tor’ s disc re tiona

ry de c ision re ga

rding a we l fare pla

n pursua n t to ERISA, it m

ust de c ide on the le ve l of ske p tic ism

it should bring to tha

t re vie w, a

nd whe the r the a dm inistra tor re a c he d its de c ision in a proc e dura lly sound fa shion. Se e Abatie v . Alta He alth &LifeIns.

3 Se e Gabrie l v

. Alask

a Ele c . Pe nsion Fund

, 773 F.3d 945, 963 (9th C ir. 2014).
4 W e note tha

t a prior c a se , whe re a

pla n a c c orde d no disc re tiona

ry a uthority , pointe d to a

possiblewe akne ss in LINA’ s de nia l position be fore the fina l re vie w. Se e M c C lurev . LifeIns. C

o. of N . Am. , 84 F.3d 1129, 1134–36 (9th C ir. 1996) (pe r c uriam ).

5 Se e Gabrie l , 773 F.3d a

t 964. 3C

o. , 458 F.3d 955, 968–69, 971–72 (9th C ir. 2006) (e n

ba nc ); se e also Fire

s tone Tire& Rubbe r C

o. v . Bruc h , 489 U.S. 101, 115, 109 S. Ct. 948, 957, 103 L. Ed. 2d 80 (1989); Saffon v . W

e lls Fargo &

C o. Long Te rm Disability

Plan , 522 F.3d 863, 872–73 (9th C ir. 2008). Thedistric t c ourt re c ogniz e d tha

t princ iple , but, in e ffe c t, de te rm i ne d tha

t the le ve l of the ske ptic ism fa c tor he re would be the ra the r m inim a l
am ount re sulting only

from LINA’ s inhe re nt c onflic t of inte re s t. W e , howe ve r, se e the c onflic t a s gre ate r tha n tha t. In a ddition to the

inhe re nt struc t

ura l c onflic t of inte re st, the re are othe r indic ia tha t sugge st a highe r le v e l of ske ptic ism is wa rrante d: (a ) LINA ne ve r dire c tly c onta c te d the origina l phy s ic ia n fore nsic
pathologist who c onduc te d the a utopsy . Tha

t would ha

ve be e n the m ost prude nt
c ourse and, inde e d, wa s sugge ste d in a n inte rna l m anua l tha

t, at le a st a

t one tim e , wa s use d by LINA. (b) LINA obta ine d a

ne w re port a fte r the prior re vie ws a nd use d tha

t
re port to re

je c t the c la im

on a ba sis quite diffe re n t from the pre viously

use d ba sis. (c ) The e vide nc e tha

t the de c e de nt a c tua lly

ha d a fa t a l c ardia c e ve nt wa s
we ak. (3) The a

bove e rrors le ave us to spe c ulate a bout wha t de c ision thedistric t
c ourt would ha

ve re a c he d ha d it fa c tore d in a highe r le ve l of ske ptic ism and ta ke n 4m ore a c c ount of LINA’ s proc e dura l e rrors. Thus, we va c ate the judgm e nt a nd
re m and to thedistric t c o urt for furthe r proc e e dings c o nsiste nt with this disposition. 6 VAC ATED a

nd REM ANDED. C osts a re to be taxe d

a ga inst LINA.

6 W e e xpre ss no opinion, howe ve r, a s to the re sult thedistric t c ourt should re a c h on re m a

nd. Nor do wepurport to opine on the m e aning of thePla n’ s re quire m e nt tha

t a de ath be “ c a

use d by an a c c ide n t ” and “ from

no othe r c a

use s.” Onc e the distric t

c ourt ha s c onside re d M a suda -C l e ve la nd’ s outsidee vide nc e and fa c t ore d he ighte ne d ske ptic i sm to a c c ount for LINA’ s struc t ura l c onflic t of inte re st and proc e dura l e rrors into its a buse of disc re tion a

na l y sis, it should re a c h its own de te rm i nation whe the r the fa c ts of this c a se re sult in c ove ra ge or la c k of c ove ra ge for M a suda -C le ve la

nd. 5