Opinion
No. 02-CV-889S.
August 6, 2004
DECISION AND ORDER
I. INTRODUCTION
In this action, Plaintiff Craig S. Snyder seeks to recover long term disability benefits under a group disability insurance policy ("the Policy") provided by his former employer and administered by Defendant First Unum Life Insurance Company. Plaintiff asserts claims pursuant to 29 U.S.C. § 1132(a)(1)(B), which is a provision of the Employee Retirement Income Security Act of 1974 ("ERISA"). Presently before this Court are dueling Motions for Judgment on the Administrative Record. For the reasons that follow, Defendant's motion is granted and Plaintiff's motion is denied.
In support of its Motion for Judgment on the Administrative Record, Defendant filed the following documents: Notice of Motion, with attached exhibit, and a memorandum in opposition to Plaintiff's Motion for Judgment on the Administrative Record and in further support of its motion. Plaintiff filed his own Motion for Judgment on the Administrative Record and a memorandum of law in opposition to Defendant's motion and in support if his motion. This Court heard oral argument on both motions on March 3, 2004, and reserved decision at that time.
II. BACKGROUND
Plaintiff is the former vice president of finance and support services for Gateway-Longview, Inc. He initially filed a claim for long term disability benefits on March 16, 1999, after undergoing a cadaver kidney transplant necessitated by chronic renal failure. (A.R., 189.) Defendant paid long term disability benefits for that claim through September 26, 1999. (A.R., 49.) Plaintiff thereafter returned to work, but then experienced a rejection episode related to his kidney transplant, and was paid additional long term disability benefits between February 11, 2000, and March 26, 2000. (A.R., 57.) Plaintiff's physician, Romesh K. Kohli, cleared Plaintiff to return to work without limitations as of March 27, 2000. (A.R., 58.)
The Administrative Record is attached to Defendant's Notice of Motion as Exhibit A.
Plaintiff returned to work on or about March 27, 2000, but went out on leave again in early May 2000, reportedly due to carpal tunnel syndrome, kidney problems, and complications from his medications. He again sought long term disability benefits from Defendant, identifying May 8, 2000, as the date of onset. (A.R., 81, 188.) By letter dated April 19, 2002, Defendant advised Plaintiff of its determination that benefits were not payable because there was insufficient evidence that he suffered from any impairment that precluded him from working in his occupation as vice president of finance and support services. (A.R., 186-189.)
By letter dated June 19, 2002, Plaintiff, through his counsel, requested that Defendant reconsider its April 19, 2002 decision based on additional information, consisting of an Internet article describing Plaintiff's medications and medical information from a neurologist, Richard K.T. Chan. (A.R., 211-215.) Plaintiff further supplemented his submissions by letter dated July 23, 2002, to which he attached medical information from Hani A. Nabi, M.D. (A.R., 218, 298.)
By letter dated July 31, 2002, Defendant again denied Plaintiff's claim for benefits. (A.R., 221-222.) Therein, Defendant noted that it had reviewed and considered the additional information Plaintiff submitted, but did not find the information sufficient to reverse its previous determination. (A.R., 222.) Defendant advised Plaintiff that he had five days within which to file an appeal with Defendant's Appeals Unit. (A.R., 222.)
On July 31, 2002, Plaintiff notified Defendant that he wished to appeal the denial of his claim and he requested that his file be sent to the Appeals Unit. (A.R., 304.) By letter dated August 30, 2002, the Appeals Unit advised Plaintiff of its determination that the initial decision denying his claim for long term disability benefits was appropriate. (A.R., 226-228.) After unsuccessful settlement discussions, this lawsuit followed. (A.R., 230-238.)
III. DISCUSSION
A. Standard of Review
Plaintiff contends that he is entitled to receive long term disability benefits under the terms of the Policy. As noted, his claim falls under 29 U.S.C. § 1132(a)(1)(B), the ERISA provision that permits a participant or beneficiary of an employee benefit plan to commence a civil lawsuit "to recover benefits due to him under the terms of his plan, to enforce his rights under the terms of the plan, or to clarify his rights to future benefits under the terms of the plan." 29 U.S.C. § 1132 (a)(1)(B).
Because there is no right to a jury trial under ERISA, the district court typically acts as the finder of fact and conducts a bench trial "on the papers." Muller v. First Unum Life Ins. Co., 341 F.3d 119, 124 (2d Cir. 2003). The court reviews a plan administrator's decision to deny benefits "under a de novo standard unless the benefit plan gives the administrator . . . discretionary authority to determine eligibility for benefits or to construe the terms of the plan."Muller, 341 F.3d at 123-24 (quoting Firestone Tire Rubber Co. v. Bruch, 489 U.S. 101, 115, 109 S. Ct. 948, 103 L. Ed. 2d 80 (1989)).
If the benefit plan vests the plan administrator with discretionary authority, the denial of benefits is subject to a deferential, "arbitrary and capricious" standard of review.Burke v. Kodak Ret. Income Plan, 336 F.3d 103, 109 (2d Cir. 2003); Pagan v. Nynex Pension Plan, 52 F.3d 438, 441 (2d Cir. 1995) ("where the written plan documents confer upon a plan administrator the discretionary authority to determine eligibility, we will not disturb the administrator's ultimate conclusion unless it is `arbitrary and capricious'"). Under this standard, the decision to deny benefits "may be overturned only if the decision is `without reason, unsupported by substantial evidence or erroneous as a matter of law.'" Kinstler v. First Reliance Standard Life Ins. Co., 181 F.3d 243, 249 (2d Cir. 1999) (quoting Pagan, 52 F.3d at 442).
In this case, it is undisputed that the Policy reserves to Defendant the discretion to determine eligibility for benefits and the authority to interpret the terms and provisions of the Policy. (A.R., 279.) Accordingly, this Court must evaluate Defendant's decision denying Plaintiff's claim under the arbitrary and capricious standard of review. Burke, 336 F.3d at 109; Pagan, 52 F.3d at 441.
However, Plaintiff argues that a heightened form of the arbitrary and capricious standard should apply because Defendant operated under a conflict of interest based on its dual status as the Policy administrator and the Policy insurer. Under this heightened standard, if a plaintiff demonstrates that a plan administrator vested with full discretion under the terms of a plan is influenced by a conflict of interest, the deference otherwise afforded the plan administrator's decision under the arbitrary and capricious standard "drops away," and the court engages in de novo review.Sullivan v. LTV Aerospace Def. Co., 82 F.3d 1251, 1256 (2d Cir. 1996). To gain the benefit of de novo review, it is the plaintiff's burden to show that "the administrator was in fact influenced by the conflict of interest." Id. (emphasis added);Pulvers v. First Unum Life Ins. Co., 210 F.3d 89, 92 (2d Cir. 2000).
Plaintiff argues that the heightened standard of review should apply because he is clearly disabled under the Policy, and therefore, Defendant's decision to deny his claim for long term disability benefits was inherently driven by its conflict of interest. This argument assumes the truth of the very matter at issue; of course every plaintiff seeking disability benefits believes he is clearly disabled under his policy. That is not the standard. A plaintiff must show that the administrator was in fact influenced by a conflict of interest. Cf. Bjork v. Eastman Kodak Co., 189 F.Supp.2d 3, 13 (W.D.N.Y. 2001) (rejecting the plaintiff's "conclusory statements that the decision to deny benefits was tainted by an inherent conflict of interest") Plaintiff has not done so. See Sullivan, 82 F.3d at 1255 (it is the plaintiff's burden to explain how the reasonableness of the defendant's decision was affected by the conflict of interest).
However, even though Plaintiff has not carried his burden, conflict of interest remains a factor that must be assessed under the arbitrary and capricious standard. As the United States Supreme Court has noted "if a benefit plan gives discretion to an administrator or fiduciary who is operating under a conflict of interest, that conflict must be weighed as a factor in determining whether there is an abuse of discretion." Firestone Tire Rubber, 489 U.S. at 115 (quotations and citation omitted); Pulvers, 210 F.3d at 92. Accordingly, this Court finds that although a heightened standard of review does not apply, the potential conflict of interest must nonetheless be considered in determining whether Defendant's decision to deny Plaintiff's claim for benefits was arbitrary and capricious.
B. Arbitrary and Capricious Standard
The arbitrary and capricious standard of review is narrow, and constitutes the "least demanding form of judicial review of administrative action." Seff v. NOITU Trust Fund, 781 F.Supp. 1037, 1040 (S.D.N.Y. 1992). Courts must examine whether the decision came as a result of a considered judgment of the relevant factors, and whether there is a "rational connection between the facts found and the choice made." Healix Healthcare, Inc. v. Metrahealth Ins. Co., No. 97 Civ. 6838, 1999 WL 61832, at *1 (S.D.N.Y. Feb. 10, 1999) (quoting Bowman Transp. v. Arkansas-Best Freight Sys., 419 U.S. 281, 285-86, 95 S.Ct. 438, 440-42, 42 L.Ed.2d 447 (1974)).
The arbitrary and capricious standard is highly deferential to the plan administrator: "The court may not upset a reasonable interpretation by the administrator." Jordan v. Ret. Comm. of Rensselaer Polytechnic Inst., 46 F.3d 1264, 1271 (2d Cir. 1995). This deferential review "applies to both plan interpretation and factual determinations." Dorato v. Blue Cross of W.N.Y., Inc., 163 F.Supp.2d 203, 209 (W.D.N.Y. 2001) (citing Kinstler, 181 F.3d at 251). As such, "it is inappropriate . . . for the trial judge to substitute his judgment for that of the plan administrator." Bella v. Metro. Life Ins. Co., No. 98-CV-150, 1999 WL 782132, at *5 (W.D.N.Y. Sept. 30, 1999).
Accordingly, the decision to deny benefits "may be overturned only if the decision is `without reason, unsupported by substantial evidence or erroneous as a matter of law.'"Kinstler, 181 F.3d at 249 (quoting Pagan, 52 F.3d at 442);Dorato, 163 F.Supp.2d at 209. "Substantial evidence in turn is such evidence that a reasonable mind might accept as adequate to support the conclusion reached by the [decisionmaker and] . . . requires more than a scintilla but less than a preponderance."Miller v. United Welfare Fund, 72 F.3d 1066, 1072 (2d Cir. 1995) (quotation and citation omitted, alteration in original). In reviewing the administrator's decision, "district courts may consider only the evidence that the fiduciaries themselves considered." Id. at 1071.
For this reason, this Court will not consider the documents from the University at Buffalo Department of Medicine, Nephrology Unit, attached as Exhibits B and C to Plaintiff's memorandum, neither of which are part of the Administrative Record. Plaintiff bears the burden with respect to the admission of additional evidence. Krizek v. Cigna Group Ins., 345 F.3d 91, 98 (2d Cir. 2003). Specifically, Plaintiff must "allege facts, with sufficient specificity that would support the existence of `good cause' permitting the admission of additional evidence beyond the administrative record." Id. at 98 n. 2 (collecting cases). While Plaintiff discusses these two documents in his memorandum,see Plaintiff's memorandum at 25-26, he has not demonstrated "good cause" for this Court to consider them as additional evidence.
C. Motions for Judgment on the Administrative Record
Plaintiff argues that he is entitled to judgment in his favor because Defendant's decision to deny his claim for long term disability benefits was arbitrary and capricious, and because Defendant denied him full and fair review of his claim. Defendant contends that this Court must uphold its decision to deny Plaintiff's claim for long term disability benefits because it was reasonable, supported by substantial evidence, and not contrary to law. The parties' positions are further discussed below.
1. Was Defendant's Decision to Deny Benefits Arbitrary and Capricious?
As an employee of Gateway-Longview, Inc., Plaintiff was covered by the Policy, which is a qualified pension plan governed by ERISA. (A.R., 249-289.) Under the Policy, it was Plaintiff's burden to notify Defendant of his claim, and to thereafter submit sufficient proof of his disability and entitlement to benefits. (A.R., 260.)
Plaintiff filed a claim for benefits with Defendant alleging a disability onset date of May 8, 2000. (A.R., 81, 188.) It was therefore incumbent upon Plaintiff to submit sufficient proof that he was disabled within the meaning of the Policy as of that date. The Policy defines "disabled" as follows:
You are disabled when UNUM determines that:
— you are limited from performing the material and substantial duties of your regular occupation due to your sickness or injury; and
— you have a 20% or more loss in your indexed monthly earnings due to the same sickness or injury.
You will continue to receive payments beyond 24 months if you are also:
— working in any occupation and continue to have a 20% or more loss in your indexed monthly earnings due to your sickness or injury; or
— not working and, due to the same sickness or injury, are unable to perform the duties of any gainful occupation for which you are reasonably fitted by education, training or experience. (A.R., 273.)
Upon review of Plaintiff's claim, Defendant determined that there was no medical reason for why Plaintiff stopped working on May 8, 2000, and concluded that Plaintiff did not suffer from an impairment that precluded him from working in his capacity as vice president of finance and support services. (A.R., 187.) Defendant therefore denied Plaintiff's claim for benefits. (A.R., 187.)
Plaintiff contends that Defendant's decision to deny him long term disability benefits is arbitrary and capricious. First, Plaintiff argues that Defendant failed to consider that it instructed him to take a leave of absence in May 2000 because he was unable to perform his job duties. Defendant denies that this ever occurred. In any event, the facts Plaintiff relies on, particularly those relative to the duties and requirements of his position, are not part of the Administrative Record, nor is there any substantiation of Plaintiff's claim that Defendant instructed him to take a leave of absence. Accordingly, this Court will not consider this argument. See Miller, 72 F.3d at 1071 (court may generally only consider information found in the administrative record).
Indeed, Plaintiff's memorandum contains no citations to the Administrative Record in support of this argument.
Plaintiff next argues that Defendant, through its reviewing medical personnel, failed to appreciate the severity of his medical condition. In essence, Plaintiff argues that Defendant's conclusion that there was no medical reason for why he stopped working in May 2000, and that his medical condition was under good control, is against the weight of the submitted medical evidence. For example, Plaintiff argues that the reviewers erred in determining that his creatinine level was "minimally increased," when in fact he contends that his level was twice or three times the normal level. Plaintiff also points to various other errors in the reviewers' notes that he argues indicate a lack of familiarity with either his medical condition or his claim file.
This Court has reviewed the Administrative Record and finds that Defendant's decision to deny Plaintiff's claim was not arbitrary and capricious. Plaintiff's claim was reviewed by a Registered Nurse, Henry Doody, and a physician, Thomas A. Reeder, M.D. (A.R., 170-168.) They reviewed the evidence that Plaintiff submitted in support of his claim and determined that Plaintiff did not suffer from an impairment that would preclude him from working. (A.R., 168.) This conclusion is supported by substantial evidence in the record.
For example, multiple entries dated before and after May 8, 2000, from Plaintiff's physician, Dr. Kohli, indicate that Plaintiff was "asymptomatic," and there are further indications in the medical evidence that Plaintiff's health condition was stable, if not improving. (A.R., 169, 170.) While it is noted in the records that Plaintiff reported fatigue and complications from his medications, this evidence was considered by Doody and Reeder and found to be insufficient to support a finding that Plaintiff suffered from an impairment of such a serious nature that it explained Plaintiff's stoppage of work in May 2000. (A.R., 169, 168.)
Moreover, Plaintiff identifies no compelling evidence explaining how his medical condition changed on or about May 8, 2000, such that he was prevented from returning to work. Again, the contemporaneous medical evidence supports Defendant's finding that Plaintiff was "asymptomatic" and that his condition was improving. The reports from Doody and Reeder indicate that they considered the submitted evidence, but did not find it sufficient to support a finding of disability, a determination that this Court finds is supported in the record and was explained to Plaintiff.
Similar review and consideration occurred during subsequent phases of the review process. For example, Susan Iannarelli, R.N., and Daniel Krell, M.D., reviewed the evidence from Drs. Richard Chan and Hani A. Nabi submitted by Plaintiff on reconsideration. (A.R., 219). Moreover, an appeals specialist, Cynthia B. Baker, considered the whole case on appeal. (A.R., 226, 227.)
In his papers, Plaintiff suggests that Defendant's medical examiners did not appreciate the complications that could arise from a kidney transplant and did not understand the medications that a kidney recipient must take. Nothing in the Administrative Record suggests that Plaintiff ever challenged the examiners' qualifications, nor has Plaintiff demonstrated in this action that comprehension of his condition requires particularized medical training beyond that of a physician or registered nurse.
As set forth above, Plaintiff disputes the conclusions Defendant drew from the medical evidence. However, Plaintiff fails to point to evidence in the record that demonstrates that he was disabled within the meaning of the Policy that Defendant either intentionally ignored or otherwise failed to consider. Plaintiff's arguments go to the weight of the evidence, not the reasonableness of Defendant's decision or whether it was supported by substantial evidence in the record. Plaintiff simply disagrees with Defendant's conclusions and decision. Moreover, even if Plaintiff identified directly contrary evidence in the record, "the mere existence of conflicting evidence does not render the . . . decision arbitrary or capricious." Lekperic v. Bldg. Serv. 32B-J Health Fund, No. 02 CV 5726, 2004 WL 1638170, at *4 (E.D.N.Y. July 23, 2004). It is not this Court's task to engage in an ad hoc weighing of the evidence or to substitute its judgment for that of the administrator. This Court must only determine whether Defendant's decision was arbitrary and capricious under the standard discussed above, and this Court finds that it was not.
Plaintiff offers two additional arguments that fail as a matter of law. First, Plaintiff argues that Defendant should have deferred to Dr. Kohli's findings, especially to his determination that Plaintiff had "not recovered fully to be able to work at a full-time job." (A.R., 92.) However, as the United States Supreme Court clarified in Black and Decker Disability Plan v. Nord, "courts have no warrant to require administrators automatically to accord special weight to the opinions of a claimant's physician; nor may courts impose on plan administrators a discrete burden of explanation when they credit reliable evidence that conflicts with a treating physician's evaluation." 538 U.S. 822, 834, 123 S.Ct. 1965, 1972, 155 L.Ed.2d 1034 (2003). Second, Plaintiff relies on his award of federal social security benefits in support of his position that he is disabled. However, social security determinations are not binding on ERISA plan administrators. See Martin v. E.I. Dupont De Nemours Co., 999 F.Supp. 416, 424 (W.D.N.Y. 1998) (noting that "while a favorable determination from the Social Security Administration may be considered, such a finding of disability is not binding on plan administrators").
This Court finds that under the extremely deferential standard that it must apply, there is no reason to disturb Defendant's decision. Defendant's medical reviewers considered the submitted medical evidence and provided Plaintiff ample opportunity to submit additional evidence in support of his claim. The Policy vests Defendant with the discretion to determine, based on the evidence submitted, whether a claimant is entitled to benefits. Defendant exercised that discretion in this case, and there is a valid basis in the administrative record for its conclusion that Plaintiff was not suffering from a disabling medical condition such that he could not perform his job. Clearly Plaintiff disagrees with Defendant's decision and would rather have had Defendant conclude that he is entitled to receive long term disability benefits under the Policy. However, Plaintiff points to no evidence in the record and offers nothing at this stage to compel a finding that Defendant's decision constitutes a clear error of judgment or was arbitrary and capricious. As such, this Court finds that Defendant's decision to deny Plaintiff's claim for benefits was not arbitrary and capricious, and Defendant is therefore entitled to judgment on the administrative record.Lekperic, 2004 WL 1638170, at *4.
2. Was Plaintiff Denied Full and Fair Review?
Plaintiff also argues that Defendant did not afford him a full and fair review of his claim as required by ERISA. ERISA provides that every employee benefit plan shall:
(1) provide adequate notice in writing to any participant or beneficiary whose claim for benefits under the plan has been denied, setting forth the specific reasons for such denial, written in a manner calculated to be understood by the participant, and
(2) afford a reasonable opportunity to any participant whose claim for benefits has been denied for a full and fair review by the appropriate named fiduciary of the decision denying the claim.29 U.S.C. § 1133.
"The purpose of the full and fair review requirement is to provide claimants with enough information to prepare adequately for further administrative review or an appeal to the federal courts." Juliano v. Health Maint. Org. of N.J., Inc., 221 F.3d 279, 287 (2d Cir. 2000) (citing DuMond v. Centex Corp., 172 F.3d 618, 622 (8th Cir. 1999)). "At the very least, a full and fair review requires that the fiduciary inform the participant or beneficiary of the evidence that the fiduciary relied upon and provide an opportunity to submit written comments or rebuttal documents." Lidoshore v. Health Fund 917, 994 F.Supp. 229, 236-37 (S.D.N.Y. 1998) (quotation and citation omitted); see also Bjork, 189 F.Supp.2d at 10-11 (discussing the full and fair review standard). Failure to provide a full and fair review may render the plan administrator's decision arbitrary and capricious. See Crocco v. Xerox Corp., 137 F.3d 105, 108 (2d Cir. 1998); Soron v. Liberty Life Assurance Co. of Boston, 318 F.Supp.2d 19, 24 (N.D.N.Y. 2004).
Although Plaintiff couches his argument as one challenging the fairness of review, a close reading of his argument reveals that he simply continues to challenge Defendant's substantive handling of his claim. Plaintiff does not argue that he was denied the opportunity to present evidence, that Defendant failed to inform him of the basis of its decision, or that he was denied the opportunity to rebut or comment on Defendant's action. The record clearly establishes that Plaintiff received detailed explanations of the denial of his claim initially, on reconsideration, and on appeal. (A.R., 189-186, 222-221, 228-226.) Moreover, Plaintiff was afforded the opportunity to comment on Defendant's decision and to submit additional information, which he did in fact do. Accordingly, this Court finds no support in the record for Plaintiff's position that he was denied the full and fair review required under ERISA.
IV. CONCLUSION
For the foregoing reasons, this Court finds that Defendant's decision to deny Plaintiff's claim for long term benefits was reasonable and supported by substantial evidence in the record. It was therefore not arbitrary and capricious, and Defendant is entitled to judgment on the administrative record. For the same reason, Plaintiff's Motion for Judgment on the Administrative Record must be denied.
V. ORDERS
IT HEREBY IS ORDERED, that Defendant's Motion for Judgment on the Administrative Record (Docket No. 12) is GRANTED.
FURTHER, that Plaintiff's Motion for Judgment on the Administrative Record (Docket No. 17) is DENIED.
FURTHER, that the Clerk of the Court is directed to close this case.
SO ORDERED.