Summary
observing that "the mere existence of conflicting evidence does not render [an administrator's] decision arbitrary or capricious."
Summary of this case from Fortune v. Group Long Term Disability PlanOpinion
No. 00 Civ. 7557 (JSM).
August 16, 2001
OPINION and ORDER
Juan Rosario ("Plaintiff"), who appears pro se, originally brought this action in the Civil Court for the City of New York against the Service Employees International Union, Local 32B-J ("Defendant") for failure to pay wages and disability health and pension benefits, and for breach of contract. Defendant removed the action to federal court pursuant to 28 U.S.C. § 1441 on the basis that Plaintiff's employee benefit plan is governed by the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. § 1001 et seq. Defendant now moves for summary judgment dismissing Plaintiff's complaint. For the reasons stated below, Defendant's motion is granted.
Plaintiff incorrectly named Defendant as Local 32B-32J in his state court complaint.
I. BACKGROUND
In 1995, Plaintiff was employed as a building maintenance worker and porter, and his responsibilities included removing garbage from his employer's building. While at work on December 12, 1995, Plaintiff slipped on some food that was left on the floor and fell on his back. He claims that he immediately experienced lower back pain. Plaintiff worked for another hour and then went home. The next day, Plaintiff returned to work, continued to suffer back pain, and reported his injury to his supervisor. He did not return to work thereafter, and was permanently terminated from his position in July 1996. Plaintiff was fifty-six years old at the time of the accident.
Since the accident, Plaintiff complains of headaches and neck and back pain that increases when he lifts, pushes, or carries heavy objects. (Duffy Aff. Ex. E.) He also claims to have trouble sitting or standing for long periods of time or walking for more than several blocks without a cane.
On December 16, 1995, Plaintiff was evaluated by Rodica Alexandrescu, M.D. ("Dr. Alexandrescu"), who found that Plaintiff was experiencing severe neck and back pain and was "totally disabled." (Duffy Aff. Ex. E.) Dr. Alexandrescu periodically evaluated Plaintiff throughout 1996 and into early 1997, finding that Plaintiff continued to suffer from pain and physical impairment. (Duffy Aff. Ex. E.) In April 1997, Dr. Alexandrescu discharged Plaintiff from physical therapy, noting that Plaintiff continued to suffer from lower back pain but had attained the maximum benefit that therapy would provide, and advised Plaintiff to return if his symptoms "recur." A few days later, Plaintiff was evaluated by Gerald Gaughan, M.D. ("Dr. Gaughan"), who also concluded that Plaintiff was "totally disabled" and recommended-a regimen of physical therapy. (Duffy Aff. Ex. E.) Dr. Gaughan issued similar evaluations in June and July 1997, and a letter from Dr. Gaughan dated February 1998 again indicates that Plaintiff is totally disabled. Neither Dr. Alexandrescu nor Dr. Gaughan is a neurologist or orthopedic surgeon. (Duffy Aff. ¶ 7.)
In October 1997, Administrative Law Judge Carl Stephan ("Judge Stephan") of the Social Security Administration Office of Hearings and Appeals found that Plaintiff was disabled within the meaning of the Social Security Act and awarded Plaintiff a period of disability benefits commencing on December 12, 1995. (Duffy Aff. Exs. F, G.) Judge Stephan found that because Plaintiff continued to suffer from tenderness and limited motion, he did not have "the residual capacity to perform past relevant work." However, Judge Stephan did find that Plaintiff "has the residual functional capacity for a full range of light work."
Defendant union participates in the Building Service 32B-J Health and Pension Fund, which is a multi-employer employee benefit fund that is governed by a Declaration of Trust and Benefit Plan ("the Plan"). The Plan is regulated by ERISA, 29 U.S.C. § 1002(1)-(2), 1132(d)(1), and is administered by a Board of Trustees ("The Trustees").
In November 1997, Plaintiff applied for disability health and pension benefits. The Plan provides that in order to be eligible for disability benefits, a member must be found to be "totally and permanently disabled," which is defined as the permanent inability "as a result of bodily injury or disease to engage in any further employment or gainful pursuit." (Duffy Aff. Ex. A.) The Plan further provides that "on the basis of medical evidence satisfactory to the Trustees . . . [t]he Trustees shall determine [the existence of a] total and permanent disability and the entitlement to a Disability Pension. . . ." Moreover, "[t]he Trustees shall . . . judge of the standard of proof required in any case and the application and interpretation of this Plan, and decisions of the Trustees shall be final and binding on all parties." (Duffy Aff. Ex. C.)
On November 17, 1997, pursuant to the provisions of the Plan, Defendants informed Plaintiff that before the Disability Claims Department could review his file, he must be examined by Dr. Michael Rubin ("Dr. Rubin"), a neurophysiologist at New York Hospital. (Duffy Aff. Ex. G.) On December 2, 1997, Plaintiff attended his medical appointment. In his written evaluation of the examination, Dr. Rubin stated that Plaintiff's range of neck motion was full, his motor, tone, bulk, and strength were normal, and his MRI report and X-rays were normal for a person of his age. (Duffy Aff. Ex. D.) He concluded that Plaintiff was not disabled and could return to work. Dr. Rubin also noted that Plaintiff walked into the examination room with a cane, but that he later saw Plaintiff walking in the hall without the cane and without apparent difficulty.
On February 11, 1998, Defendant denied Plaintiff's application for disability benefits and a disability pension primarily because of the findings of Dr. Rubin and Judge Stephan, who had concluded that Plaintiff had the capacity to engage in light work. (Duffy Aff. ¶¶ 8-9; Ex. G.) Defendant reasoned that by definition, Plaintiff is ineligible for benefits "since the 32B-J Plan requires an applicant to be incapable of working in any capacity." (Duffy Aff. ¶ 8.) Plaintiff's record also included the reports of Dr. Alexandrescu and Dr. Gaughan, as well as X-ray and MRI reports that showed generally normal or unremarkable findings. (Duffy Aff. ¶ 7, 11.) Plaintiff appealed this decision and on March 13, 1998 and August 20, 1998, Defendant's medical advisor and its Appeals Committee upheld the Trustees' decision.
In April 1996, Igor Stiler, M.D., a neurologist, examined Plaintiff and found that his sensory responses were normal for a patient of his age. (Duffy Aff. Ex. G.) In December 1995 and October 1996, Plaintiff was examined by Robert Schepp, M.D. ("Dr. Schepp"), a radiologist, who concluded that the X-rays and MRI of Plaintiff's spine and its surrounding soft tissues were normal. (Duffy Aff. Ex. G.)
On September 22, 2000, Plaintiff filed this complaint alleging that Defendant owes him disability benefits and pension payments that have accrued since December 12, 1995. Plaintiff also indicated in his complaint that Defendant owes him wages, but Plaintiff has not elaborated on the nature of this claim
II. DISCUSSION
In general, an administrator's denial of benefits under an ERISA-governed employee benefit plan is reviewed de novo. See Firestone Tire Rubber Co. v. Bruch, 489 U.S. 101, 115, 109 S. Ct. 948, 957 (1989); Kinstler v. First-Reliance Standard Life Ins. Co., 181 F.3d 243, 250-251 (2d Cir. 1999). However, where the plan grants the administrator discretion to determine eligibility for benefits or to construe the terms of the plan, the administrator's decision will be reviewed under an arbitrary and capricious standard. See Firestone, 489 U.S. at 115; 109 5. Ct. at 957.
The language of Defendant's Plan plainly affords the Trustees discretion to determine whether an applicant for disability benefits meets the standard set forth in the Plan. The Plan defines "total and permanent disability" as the inability "to engage in any further employment or gainful pursuit." The Plan provides that an applicant will be deemed disabled if he submits medical evidence of total and permanent disability that is "satisfactory to the Trustees." The Plan further provides that the Trustees "shall determine total and permanent disability and the entitlement to a Disability Pension . . . based on information submitted." Finally, the Plan states that the Trustees shall determine the standard of proof required in any case, as well as the "application and interpretation" of the Plan, and that their decision will be "final and binding on all parties."
In Kinstler, the Second Circuit held:
Though we reiterate that no one word or phrase must always be used to confer discretionary authority, the administrator's burden to demonstrate insulation from de novo review requires either language stating that the award of benefits is within the discretion of the plan administrator or language that is plainly the functional equivalent of such wording.Kinstler, 181 F.3d at 252; see also Jordan v. Retirement Comm., 46 F.3d 1264, 1269-71 (2d Cir. 1995). While the Plan sets forth a specific definition of "total and permanent disability," the determination of what type of medical evidence satisfies that requirement is left to the discretion of the Trustees. Moreover, the Plan specifically indicates that the Trustees will determine whether total and permanent disability exists, and that the Trustees' determination of the application of the Plan's provisions will be final and binding. Therefore, the highly deferential arbitrary and capricious standard applies to the factual determination of whether Plaintiff qualified for benefits.
Under this standard, the decision of the Trustees may be overturned only if it was "without reason, unsupported by substantial evidence or erroneous as a matter of law." Pagan v. Nynex Pension Plan, 52 F.3d 438, 442 (2d Cir. 1995). In making this determination, courts ask "whether the decision was based on a consideration of the relevant factors and whether there has been a clear error of judgment." Jordan, 46 F.3d at 1271 (internal quotations omitted).
The Trustees' decision to deny Plaintiff his disability benefits was not clearly erroneous or unsupported by the facts. First, Dr. Rubin, who evaluated Plaintiff in December 1997, found that Plaintiff's range of motion was normal and that his X-rays and MRI reports were within a normal range. Dr. Rubin concluded that Plaintiff could return to work. Second, Judge Stephan, who found that Plaintiff was disabled for the purposes of receiving social security benefits, also found that Plaintiff could perform a full range of light work. Based primarily on these findings, the Trustees concluded that Plaintiff could earn gainful employment because he could work in some capacity, thereby precluding his eligibility for pension benefits under the terms of the Plan.
Although Dr. Alexandrescu and Dr. Gaughan found Plaintiff to be "totally disabled" for the period of time that he was under their care, the mere existence of conflicting evidence does not render the Trustee's decision arbitrary or capricious. See Wojciechowski v. Metropolitan Life Ins. Co., 75 F. Supp.2d 256, 262 (S.D.N.Y. 1999), aff'd, 2001 WL 38263 (2d Cir. 2001); Kocsis v. Standard Ins. Co., 142 F. Supp.2d 241, 252-53 (D. Conn. 2001). The Plan afforded the Trustees discretion to weigh different medical opinions and to determine, based upon the evidence submitted, whether an applicant is physically able to work. The Trustees exercised their discretion by relying primarily on Dr. Rubin's and Judge Stephan's conclusion that Plaintiff could engage in light work.
The procedures that Defendant followed also indicate that a careful and informed decision was reached. Defendant maintained a comprehensive file of Plaintiff's correspondence and test results, and referred Plaintiff to Dr. Rubin for evaluation. Both the medical advisor and the Appeals Committee reviewed Plaintiff's file and upheld the Trustees' decision. Thus, the record indicates that the decision to deny Plaintiff's requested pension benefits was made after careful examination of Plaintiff's record.
III. CONCLUSION
For the foregoing reasons, Defendants' motion for summary judgment is granted.
SO ORDERED.