What happens when a disability plan asks for a laboratory result that cannot establish the condition at issue? In Salomaa v. Honda Long Term Disability Plan, the Ninth Circuit considered that question in a long-term disability claim involving chronic fatigue syndrome.
Samuel Salomaa had worked for Honda for more than 20 years before severe fatigue and difficulty concentrating disrupted his work and daily life. He applied for benefits, but the plan administrator denied the claim. The district court upheld the decision; in its amended 2011 opinion, the Ninth Circuit reversed and ordered an award of benefits.
A demand for the wrong kind of proof
The administrator emphasized normal laboratory results and a lack of objective findings. The court explained that, on the record before it, blood tests were used to rule out alternative conditions rather than establish chronic fatigue syndrome itself. The majority also discussed a later coverage-position paper from a CIGNA affiliate that described the limits of diagnostic testing for chronic fatigue syndrome. The court held that conditioning an award on evidence that cannot exist is arbitrary and capricious.
This does not mean a diagnosis alone establishes entitlement to benefits, or that medical testing and functional evidence have no value. The question is whether the requested evidence is meaningful for the condition and the plan’s disability definition. Judge Hall dissented, emphasizing the difference between proving a diagnosis and proving disabling functional limitations.
The review process mattered too
The majority considered more than a request for laboratory proof. It described shifting reasons for denial, the failure to address a Social Security disability award, and the administrator’s reliance on physicians who reviewed the file without examining Salomaa. The administrator did not provide the reports of its reviewing physicians to Salomaa or his lawyer, limiting their opportunity to respond.
The court concluded that these facts, considered together with the administrator’s conflict as both insurer and decision-maker, showed an abuse of discretion. Its amended opinion addressed the effect of that structural conflict; the decision should not be read as announcing the same standard for every plan.
Building a meaningful record
For a claimant, a useful appeal may connect medical findings, symptoms, treatment, and documented limitations to the actual duties required under the plan. A physician’s explanation of what tests can—and cannot—show may also help address a denial’s stated rationale.
Salomaa is a Ninth Circuit decision based on a particular record and the medical evidence available in that case. It does not guarantee a result in another claim, and current medical standards and plan language should be considered separately.
Feden Law Group can help assess an ERISA disability denial or appeal. Learn about our disability practice or schedule an initial consultation.
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