NOT FOR PUBLICATION FILED UNITED STATES COURT OF APPEALS MAY 31 2024 MOLLY C. DWYER, CLERK U.S. COURT OF APPEALS FOR THE NINTH CIRCUIT
BRISTOL SL HOLDINGS, INC., a No. 23-55019 California corporation, in its capacity as the owner of the claims for Sure Haven, Inc., a D.C. No. California corporation, 8:19-cv-00709-PSG-ADS
Plaintiff-Appellant, MEMORANDUM* v.
CIGNA HEALTH AND LIFE INSURANCE COMPANY, a Connecticut corporation; CIGNA BEHAVIORAL HEALTH, INC., a Connecticut corporation,
Defendants-Appellees.
Appeal from the United States District Court for the Central District of California Philip S. Gutierrez, Chief District Judge, Presiding
Argued and Submitted December 7, 2023 San Francisco, California
Before: S.R. THOMAS, BRESS, and JOHNSTONE, Circuit Judges.
We consider Bristol SL Holdings, Inc.’s ERISA claim against defendants
Cigna Health and Life Insurance Company and Cigna Behavioral Health, Inc.
* This disposition is not appropriate for publication and is not precedent except as provided by Ninth Circuit Rule 36-3. (collectively, “Cigna”). The district court granted summary judgment to Cigna and
denied Bristol’s motion for reconsideration. We have jurisdiction under 28 U.S.C.
§ 1291. Reviewing the grant of summary judgment de novo, Silverado Hospice, Inc.
v. Becerra, 42 F.4th 1112, 1118 (9th Cir. 2022), we affirm.1
1. The district court correctly granted summary judgment to Cigna on
Bristol’s claim for benefits due under an ERISA plan. 29 U.S.C. § 1132(a)(1)(B).
a. The district court correctly applied abuse of discretion review to
Cigna’s denial of reimbursement. “When a plan does not confer discretion on the
administrator ‘to determine eligibility for benefits or to construe the terms of the
plan,’ a court must review the denial of benefits de novo . . . .” Abatie v. Alta Health
& Life Ins. Co., 458 F.3d 955, 963 (9th Cir. 2006) (en banc) (quoting Firestone Tire
& Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989)). “But if the plan does confer
discretionary authority as a matter of contractual agreement, then the standard of
review shifts to abuse of discretion.” Id. (citing Firestone, 489 U.S. at 115).
Discretionary authority exists when the plan “give[s] a plan administrator the
authority to interpret the plan’s terms and to make final benefits
determinations . . . .” Id. at 964.
Cigna proffered various plan documents all stating that “[t]he Plan
1 In a concurrently filed opinion, we hold that ERISA preempts Bristol’s state law claims against Cigna for breach of contract and promissory estoppel.
2 Administrator delegates to Cigna discretionary authority to interpret and apply plan
terms and to make factual determinations in connection with its review of claims
under the plan.” The district court correctly found this language sufficient to confer
discretion on Cigna. See id. at 963–64.
Bristol argues that Cigna’s example plan documents are insufficient because
they are summary plan descriptions (SPDs) rather than formal plans. At oral
argument, Cigna’s counsel appeared to agree that the documents Cigna relied upon
below were SPDs. Even so, our conclusion that abuse of discretion review applies
is unaltered.
Statements contained in SPDs “do not themselves constitute the terms of the
plan for purposes of” § 1132(a)(1)(B). CIGNA Corp. v. Amara, 563 U.S. 421, 438
(2011). But as we have explained, “Amara addressed only the circumstance where
both a governing plan document and an SPD existed, and the plan administrator
sought to enforce the SPD’s terms over those of the plan document.” Prichard v.
Metropolitan Life Ins. Co., 783 F.3d 1166, 1170 (9th Cir. 2015). An SPD can still
operate as a plan document for purposes of § 1132(a)(1)(B) if it is “part of the Plan’s
‘written instrument.’” Id. at 1171. That is, “an SPD may constitute a formal plan
document, consistent with Amara, so long as the SPD neither adds to nor contradicts
the terms of existing Plan documents.” Mull for Mull v. Motion Picture Indus.
Health Plan, 865 F.3d 1207, 1210 (9th Cir. 2017) (quoting Prichard, 783 F.3d at
3 1170).
Here, each of Cigna’s example plan documents states that it is part of a “Plan”
and that it “takes the place of any documents previously issued . . . which described
benefits.” A Cigna witness testified without contradiction that “the Cigna plans give
Cigna the authority to interpret and enforce the terms of those plans.” And Cigna in
the district court offered to “supplement [its] exemplar[s]” with “other plan
documents, which Cigna did not provide only because they are voluminous and
thousands of pages long.” Bristol did not take Cigna up on that offer, nor did it
challenge the adequacy of Cigna’s example documents by moving to compel
production of additional documents or asking to extend the discovery period to
obtain them (Cigna represents that these documents were in fact produced).
Considering that all the evidence in the record supports Cigna having discretionary
authority to interpret plan terms, the burden shifted to Bristol to provide some
evidence that the plans lacked discretionary authority. See Anderson v. Liberty
Lobby, Inc., 477 U.S. 242, 256 (1986). Bristol identified no such evidence.
We also reject Bristol’s argument that de novo review is required because
Cigna briefed only exemplar plan documents, as opposed to 106 separate documents
corresponding to each patient whose claims Cigna denied. As noted, Cigna offered
to provide the court with additional documents and offered uncontroverted testimony
that the plans “give Cigna the authority to interpret and enforce [their] terms.”
4 Where Bristol failed to meaningfully challenge this conclusion, Cigna’s
representative submissions, supporting testimony, and offer of proof were sufficient
to carry its summary judgment burden. See T.W. Elec. Serv., Inc. v. Pacific Elec.
Contractors Ass’n, 809 F.2d 626, 630 (9th Cir. 1987).
b. Under abuse of discretion review, “a plan administrator’s decision ‘will
not be disturbed if reasonable.’” Stephan v. Unum Life Ins. Co. of Am., 697 F.3d
917, 929 (9th Cir. 2012) (quoting Conkright v. Frommert, 559 U.S. 506, 521 (2010)).
The abuse of discretion standard is “deferential,” id., and a plan administrator
contravenes it “only if it (1) renders a decision without explanation, (2) construes
provisions of the plan in a way that conflicts with the plain language of the plan, or
(3) relies on clearly erroneous findings of fact,” Boyd v. Bert Bell/Pete Rozelle NFL
Players Retirement Plan, 410 F.3d 1173, 1178 (9th Cir. 2005). There was no abuse
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NOT FOR PUBLICATION FILED UNITED STATES COURT OF APPEALS MAY 31 2024 MOLLY C. DWYER, CLERK U.S. COURT OF APPEALS FOR THE NINTH CIRCUIT
BRISTOL SL HOLDINGS, INC., a No. 23-55019 California corporation, in its capacity as the owner of the claims for Sure Haven, Inc., a D.C. No. California corporation, 8:19-cv-00709-PSG-ADS
Plaintiff-Appellant, MEMORANDUM* v.
CIGNA HEALTH AND LIFE INSURANCE COMPANY, a Connecticut corporation; CIGNA BEHAVIORAL HEALTH, INC., a Connecticut corporation,
Defendants-Appellees.
Appeal from the United States District Court for the Central District of California Philip S. Gutierrez, Chief District Judge, Presiding
Argued and Submitted December 7, 2023 San Francisco, California
Before: S.R. THOMAS, BRESS, and JOHNSTONE, Circuit Judges.
We consider Bristol SL Holdings, Inc.’s ERISA claim against defendants
Cigna Health and Life Insurance Company and Cigna Behavioral Health, Inc.
* This disposition is not appropriate for publication and is not precedent except as provided by Ninth Circuit Rule 36-3. (collectively, “Cigna”). The district court granted summary judgment to Cigna and
denied Bristol’s motion for reconsideration. We have jurisdiction under 28 U.S.C.
§ 1291. Reviewing the grant of summary judgment de novo, Silverado Hospice, Inc.
v. Becerra, 42 F.4th 1112, 1118 (9th Cir. 2022), we affirm.1
1. The district court correctly granted summary judgment to Cigna on
Bristol’s claim for benefits due under an ERISA plan. 29 U.S.C. § 1132(a)(1)(B).
a. The district court correctly applied abuse of discretion review to
Cigna’s denial of reimbursement. “When a plan does not confer discretion on the
administrator ‘to determine eligibility for benefits or to construe the terms of the
plan,’ a court must review the denial of benefits de novo . . . .” Abatie v. Alta Health
& Life Ins. Co., 458 F.3d 955, 963 (9th Cir. 2006) (en banc) (quoting Firestone Tire
& Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989)). “But if the plan does confer
discretionary authority as a matter of contractual agreement, then the standard of
review shifts to abuse of discretion.” Id. (citing Firestone, 489 U.S. at 115).
Discretionary authority exists when the plan “give[s] a plan administrator the
authority to interpret the plan’s terms and to make final benefits
determinations . . . .” Id. at 964.
Cigna proffered various plan documents all stating that “[t]he Plan
1 In a concurrently filed opinion, we hold that ERISA preempts Bristol’s state law claims against Cigna for breach of contract and promissory estoppel.
2 Administrator delegates to Cigna discretionary authority to interpret and apply plan
terms and to make factual determinations in connection with its review of claims
under the plan.” The district court correctly found this language sufficient to confer
discretion on Cigna. See id. at 963–64.
Bristol argues that Cigna’s example plan documents are insufficient because
they are summary plan descriptions (SPDs) rather than formal plans. At oral
argument, Cigna’s counsel appeared to agree that the documents Cigna relied upon
below were SPDs. Even so, our conclusion that abuse of discretion review applies
is unaltered.
Statements contained in SPDs “do not themselves constitute the terms of the
plan for purposes of” § 1132(a)(1)(B). CIGNA Corp. v. Amara, 563 U.S. 421, 438
(2011). But as we have explained, “Amara addressed only the circumstance where
both a governing plan document and an SPD existed, and the plan administrator
sought to enforce the SPD’s terms over those of the plan document.” Prichard v.
Metropolitan Life Ins. Co., 783 F.3d 1166, 1170 (9th Cir. 2015). An SPD can still
operate as a plan document for purposes of § 1132(a)(1)(B) if it is “part of the Plan’s
‘written instrument.’” Id. at 1171. That is, “an SPD may constitute a formal plan
document, consistent with Amara, so long as the SPD neither adds to nor contradicts
the terms of existing Plan documents.” Mull for Mull v. Motion Picture Indus.
Health Plan, 865 F.3d 1207, 1210 (9th Cir. 2017) (quoting Prichard, 783 F.3d at
3 1170).
Here, each of Cigna’s example plan documents states that it is part of a “Plan”
and that it “takes the place of any documents previously issued . . . which described
benefits.” A Cigna witness testified without contradiction that “the Cigna plans give
Cigna the authority to interpret and enforce the terms of those plans.” And Cigna in
the district court offered to “supplement [its] exemplar[s]” with “other plan
documents, which Cigna did not provide only because they are voluminous and
thousands of pages long.” Bristol did not take Cigna up on that offer, nor did it
challenge the adequacy of Cigna’s example documents by moving to compel
production of additional documents or asking to extend the discovery period to
obtain them (Cigna represents that these documents were in fact produced).
Considering that all the evidence in the record supports Cigna having discretionary
authority to interpret plan terms, the burden shifted to Bristol to provide some
evidence that the plans lacked discretionary authority. See Anderson v. Liberty
Lobby, Inc., 477 U.S. 242, 256 (1986). Bristol identified no such evidence.
We also reject Bristol’s argument that de novo review is required because
Cigna briefed only exemplar plan documents, as opposed to 106 separate documents
corresponding to each patient whose claims Cigna denied. As noted, Cigna offered
to provide the court with additional documents and offered uncontroverted testimony
that the plans “give Cigna the authority to interpret and enforce [their] terms.”
4 Where Bristol failed to meaningfully challenge this conclusion, Cigna’s
representative submissions, supporting testimony, and offer of proof were sufficient
to carry its summary judgment burden. See T.W. Elec. Serv., Inc. v. Pacific Elec.
Contractors Ass’n, 809 F.2d 626, 630 (9th Cir. 1987).
b. Under abuse of discretion review, “a plan administrator’s decision ‘will
not be disturbed if reasonable.’” Stephan v. Unum Life Ins. Co. of Am., 697 F.3d
917, 929 (9th Cir. 2012) (quoting Conkright v. Frommert, 559 U.S. 506, 521 (2010)).
The abuse of discretion standard is “deferential,” id., and a plan administrator
contravenes it “only if it (1) renders a decision without explanation, (2) construes
provisions of the plan in a way that conflicts with the plain language of the plan, or
(3) relies on clearly erroneous findings of fact,” Boyd v. Bert Bell/Pete Rozelle NFL
Players Retirement Plan, 410 F.3d 1173, 1178 (9th Cir. 2005). There was no abuse
of discretion here.
First, Cigna explained its claim denials “in reasonably clear language, with
specific reference to the plan provisions that form the basis for the denial.” Booton
v. Lockheed Med. Ben. Plan, 110 F.3d 1461, 1463 (9th Cir. 1997). Before denying
Sure Haven’s claims, Cigna sent Sure Haven a letter citing a plan provision
permitting Cigna to exclude from coverage “charges which [members] are not
obligated to pay or for which [members] are not billed.” Cigna explained that, given
its suspicion that Sure Haven was forgiving patient financial contributions, or “fee-
5 forgiving,” Cigna would begin to deny Sure Haven’s claims unless Sure Haven
established proof of patient payment with appropriate documentation. Then, with
respect to each claim it denied pursuant to this “fee-forgiving flag,” Cigna sent Sure
Haven an “Explanation of Medical Benefits Report” that directed Sure Haven to the
relevant plan provision, instructed Sure Haven that Cigna would “reconsider”
reimbursement upon receiving sufficient documentation, and informed Sure Haven
of its right to seek review of Cigna’s final decision. These communications satisfied
Cigna’s obligation to engage in “meaningful dialogue” concerning its claim denials.
Booton, 110 F.3d at 1463.
Second, Cigna’s claim denials were premised on a permissible interpretation
of its plans. As Cigna explained to Sure Haven, Cigna interprets the operative plan
provision to mean that “[i]f a Cigna customer is not obligated to pay or billed a
charge, any claim for reimbursement for any part of that charge under such a contract
or benefit plan is not covered.” Bristol does not challenge Cigna’s interpretation of
the plan, and courts have held that this interpretation of identical or nearly identical
plan language is reasonable. See N. Cypress Med. Ctr. Operating Co., Ltd. v. Cigna
Healthcare, 952 F.3d 708, 711, 715 (5th Cir. 2020); Kennedy v. Conn. Gen. Life Ins.
Co., 924 F.2d 698, 701–02 (7th Cir. 1991); see also SmileCare Dental Grp. v. Delta
Dental Plan of Cal., Inc., 88 F.3d 780, 783 (9th Cir. 1996).
Third, the evidence supports Cigna’s claim denials. Cigna had a reasonable
6 basis for its initial suspicion that Sure Haven was waiving patient payments. After
an internal investigation raised red flags, Cigna sent letters to thirty Sure Haven
patients requesting billing information, made an undercover inquiry as to Sure
Haven’s rates, and conducted audits of Sure Haven’s patient records. Each of those
efforts pointed to fee-forgiving, with Cigna’s outside investigator ultimately
unearthing “[o]nly limited evidence that [Sure Haven] ever [] billed for co-pays or
deductibles.”
Cigna also had a reasonable basis for concluding that Sure Haven failed to
provide the proof of patient payment that Cigna requested pursuant to its fee-
forgiving flag. Of the many pages of documents that Bristol alleges constitute proof
of patient payment submitted to Cigna, only a small minority plausibly respond to
Cigna’s request for evidence that the Cigna insureds actually incurred the expense.
And it is impossible to discern whether those few responsive documents were
submitted to Cigna within a reasonable time after Cigna’s claim denials—which
took place in 2015—or were instead submitted several years later, during settlement
negotiations.
Bristol’s mixed bag of submissions was far from “reliable evidence” that
Cigna was required to credit, Black & Decker Disability Plan v. Nord, 538 U.S. 822,
834 (2003), and may not even have been properly before Cigna during its benefits
determinations, see Tremain v. Bell Indus., Inc., 196 F.3d 970, 976 (9th Cir. 1999).
7 On this record, there thus can be no “definite and firm conviction” that Cigna’s
denials were mistaken, or that Cigna relied on “clearly erroneous findings of fact.”
Boyd, 410 F.3d at 1178–79 (citation omitted). We note that the district court likewise
found that Sure Haven’s documentation “indicated a lack of cost-sharing with
patients.”
Finally, we find no error in the district court’s conclusion that Cigna was not
conflicted since “the vast majority of plans administered by Cigna are ‘self-funded,’”
meaning that Cigna does not stand to gain from denying claims. Cigna’s unrebutted
testimony below was that “Cigna is not paid a fee or any portion of the ‘savings’
generated through denying claims due to suspicion of fraud.” Where Bristol
countered with no affirmative evidence of a conflict of interest, Cigna’s evidence
was sufficient for purposes of summary judgment. See Anderson, 477 U.S. at 249–
50.
2. We review the denial of a motion for reconsideration for abuse of
discretion. Havensight Cap. LLC v. Nike, Inc., 891 F.3d 1167, 1171 (9th Cir. 2018).
The “[d]enial of a motion as the result of a failure to comply with local rules is well
within a district court’s discretion.” Tri-Valley CAREs v. U.S. Dep’t of Energy, 671
F.3d 1113, 1131 (9th Cir. 2012). Here, the district court did not abuse its discretion
in concluding that Bristol’s motion for reconsideration contravened Central District
Local Rules 7-3 and 7-18. And the motion lacked merit in any event.
8 AFFIRMED.