This educational guide is based on the linked primary sources. It is not a Court publication, is not affiliated with the Court, and is not legal advice.
In brief
Overview
According to Lee T. Paterson, the Ninth Circuit has a treating‑physician rule in ERISA cases that requires a plan administrator to either accept the treating physician’s opinion or reject it with specific legitimate reasons based on substantial evidence.
According to American Medical Association, the American Medical Association reports that 39 % of treating physicians misrepresent symptoms, diagnosis, and severity of illness when patients submit insurance claims.
The petitioner argues that treating physicians’ misrepresentations give them special weight, deference, and a presumption in ERISA disability‑benefit determinations.
The respondent notes that the Secretary’s 2002 regulations imposed many new requirements on plan administrators, taking a different approach from earlier practice.
According to Ms. Blatt, the respondent contends there is no evidence that the plan considered the treating physician’s opinion.
If an explanation is inadequate, the proper consequence is a remand to the administrator for further explanation, not a de novo standard of review.
According to Mr. Rohlfing, the respondent argues that the treating‑physician rule is unrelated to the concept of actual bias.
- [1] 8eee1b8e13e6dc46d26a-r1-c9baf0b805ab217e.pdf, p. 3
- [2] 8eee1b8e13e6dc46d26a-r1-c9baf0b805ab217e.pdf, p. 52
- [3] 8eee1b8e13e6dc46d26a-r1-c9baf0b805ab217e.pdf, p. 53
- [4] 8eee1b8e13e6dc46d26a-r1-c9baf0b805ab217e.pdf, p. 19
- [5] 8eee1b8e13e6dc46d26a-r1-c9baf0b805ab217e.pdf, p. 19
- [6] 8eee1b8e13e6dc46d26a-r1-c9baf0b805ab217e.pdf, p. 23
- [7] 8eee1b8e13e6dc46d26a-r1-c9baf0b805ab217e.pdf, p. 36
Background and question before the Court
According to Justice O'Connor, justice O’Connor asked whether there is a requirement to give reasons when there is a difference of views between the treating physician and the expert.
A Justice asked about the connection between the treating‑physician rule and the concept of actual bias.
According to Justice, a Justice inquired whose money is at stake in the Social Security cases.
What each side argues
Petitioner Position
According to Lee T. Paterson, the Ninth Circuit’s treating‑physician rule requires a plan administrator to accept a treating physician’s opinion or reject it with specific legitimate reasons based on substantial evidence.
Respondent Position
According to Mr. Rohlfing, the treating‑physician rule is unrelated to the concept of actual bias.
According to Mr. Rohlfing, the employer’s statement supported the proposition of disability rather than the proposition of no disability.
What happened at oral argument
According to Justice O'Connor, justice O’Connor asked whether a plan must give reasons when the treating physician and the expert disagree.
According to Justice, justice questioned the link between the treating‑physician rule and actual bias.
Justice asked whose money is at stake in the Social Security cases.
According to Lee T. Paterson, paterson explained the Ninth Circuit’s treating‑physician rule that requires acceptance or legitimate rejection based on substantial evidence.
Ms. Blatt argued there is no evidence the plan considered the treating physician’s opinion and noted the 2002 regulatory overhaul.
Ms. Blatt stated that the proper consequence of an inadequate explanation is a remand for further explanation, not a de novo review.
According to Mr. Rohlfing, rohlfing argued that the treating‑physician rule is unrelated to actual bias and highlighted an employer statement that supported a disability finding.
The American Medical Association submitted statistics that 39 % of treating physicians misrepresent information in insurance claims.
- [1] 8eee1b8e13e6dc46d26a-r1-c9baf0b805ab217e.pdf, p. 4
- [2] 8eee1b8e13e6dc46d26a-r1-c9baf0b805ab217e.pdf, p. 36
- [3] 8eee1b8e13e6dc46d26a-r1-c9baf0b805ab217e.pdf, p. 44
- [4] 8eee1b8e13e6dc46d26a-r1-c9baf0b805ab217e.pdf, p. 3
- [5] 8eee1b8e13e6dc46d26a-r1-c9baf0b805ab217e.pdf, p. 19
- [6] 8eee1b8e13e6dc46d26a-r1-c9baf0b805ab217e.pdf, p. 23
- [7] 8eee1b8e13e6dc46d26a-r1-c9baf0b805ab217e.pdf, p. 36
- [8] 8eee1b8e13e6dc46d26a-r1-c9baf0b805ab217e.pdf, p. 50
- [9] 8eee1b8e13e6dc46d26a-r1-c9baf0b805ab217e.pdf, p. 52
What the Court decided
Why it matters
According to Lee T. Paterson, the treating‑physician rule determines how disability benefits are evaluated under ERISA, directly affecting claimants’ access to benefits.
According to American Medical Association, misrepresentation by treating physicians, as highlighted by AMA statistics, can influence the outcome of disability‑benefit determinations.
According to Justice O'Connor, the case raises procedural‑fairness questions about whether plan administrators must provide reasons when rejecting a treating physician’s opinion.
According to Justice, the outcome could affect how courts address claims that the treating‑physician rule creates actual bias in benefit determinations.
Terms to know
No glossary terms are available for this guide.
Primary sources
Read the source materials on the official site or open the immutable repository copy used for this guide.
- 8eee1b8e13e6dc46d26a-r1-c9baf0b805ab217e.pdforal argument transcript
Guide generated September 20, 2026. Automated validation accepted this version.