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TOMCZYSCYN v. TEAMSTERS

July 26, 1985

JOHN TOMCZYSCYN and JOSEPHINE TOMCZYSCYN, Parents and Beneficiaries of GREGORY TOMCZYSCYN, Deceased
v.
TEAMSTERS, LOCAL 115 HEALTH & WELFARE FUND



The opinion of the court was delivered by: LUONGO

 Plaintiffs John and Josephine Tomczyscyn have returned to this court following the denial of their request for $15,000.00 in life insurance benefits by the trustees of Teamsters, Local 115 Health and Welfare Fund ("Fund"). Plaintiffs allege that they are entitled to receive the death benefit as beneficiaries of their deceased son Gregory Tomczyscyn. On July 10, 1984, I granted the Fund's motion for summary judgment in plaintiffs' initial lawsuit on the ground that plaintiffs had failed to exhaust their right to appeal to the Fund's trustees. Because the Fund had failed to notify plaintiffs of their appeal rights, however, I granted the motion without prejudice to plaintiffs' right to file a second action if exhaustion proved unsuccessful. Tomczyscyn v. Teamsters, Local 115 Health and Welfare Fund, 590 F. Supp. 211 (E.D.Pa. 1984). Presently before me is the Fund's motion for summary judgment on the merits of plaintiffs' claim. I conclude that the trustees' decision passes muster under the limited standard of review applicable in such cases. I must therefore grant the motion.

 I.

 As more fully described in my earlier opinion, Gregory Tomczyscyn worked for Air Master Corporation from July, 1981 until August or September, 1981. Air Master was party to a collective bargaining agreement with Teamsters Union Local 115 pursuant to which an employee health and welfare benefit plan was established. One of the provisions of the benefit plan was a $15,000.00 death benefit for covered employees. There is no dispute that Gregory became eligible for the death benefit at some point during his employment with Air Master.

 On August 25, 1981 Gregory suffered severe injuries in a work-related accident. Although he made one or two attempts to return to work in August or September, 1981, Gregory did not thereafter resume employment.

 Gregory's separation from Air Master Corporation had a significant impact on his eligibility for benefits under the health and welfare plan. Because Gregory was disabled by his occupational accident, the plan maintained his eligibility for benefits for a period of twenty-six (26) weeks. *fn1" The plan also enabled Gregory to maintain his eligibility for the death benefit after twenty-six weeks of disability. To continue the death benefit in effect, Gregory was required to submit proof of his "total and permanent disability . . . within the twelve month period of disability and yearly thereafter . . . ." *fn2"

 The parties dispute whether Gregory was "totally and permanently" disabled during the interval between his accident and his death. Relying on a determination of eligibility for disability benefits by the Social Security Administration, a waiver of premiums by Gregory's personal life insurance carrier, and Gregory's medical records, plaintiffs argue that Gregory's condition clearly precluded employment at any time after his accident. The Fund attempts to distinguish the decisions of the Social Security Administration and Gregory's insurance carrier on the ground that the plan requires proof of a disability that is total and permanent. The Fund also interprets Gregory's medical records as suggesting the possibility that Gregory could eventually return to work.

 It is undisputed, however, that Gregory failed to establish his total and permanent disability with the Fund within one year of his accident. Nevertheless, as plaintiffs point out, the Fund accepted payments from Air Master Corporation on Gregory's behalf for the months of July through September, 1982, several months after his eligibility allegedly ceased. In addition, plaintiffs note that the Fund paid two claims, unrelated medical bills, submitted on behalf of Gregory in October, 1982.

 II.

 III.

 In an action to overturn a denial of benefits by the trustees of an employee benefit plan, the plaintiff bears the burden of establishing that the trustees' decision was arbitrary and capricious. Gaines v. Amalgamated Insurance Fund, 753 F.2d 288 (3d Cir. 1985); Wolf v. National Shopmen Pension Fund, 728 F.2d 182 (3d Cir. 1984); Rosen v. Hotel and Restaurant Employees and Bartenders Union, 637 F.2d 592 (3d Cir.), cert. denied, 454 U.S. 898, 70 L. Ed. 2d 213, 102 S. Ct. 398 (1981). Judicial review of the trustees' interpretation of benefit plan documents is similarly restricted to the arbitrary and capricious standard. Where a provision in an employee benefits plan is susceptible of differing interpretations, the trustees' "interpretation should be upheld even if the court disagrees with it, so long as the interpretation is rationally related to a valid plan purpose and not contrary to the plain language of the plan." Gaines, 753 F.2d at 289.

 Our court of appeals recently emphasized the degree of deference accorded to trustees' application of benefit plan eligibility requirements. District 2, United Mine Workers of America v. Helen Mining Company, 762 F.2d 1155 (3d Cir. 1985). In Helen Mining Company, the court held that the trustees of an employee benefit plan did not act arbitrarily and capriciously in denying a claim related to surgery for which the claimant had not sought or obtained prior approval. The court rejected the claimant's argument that the trustees should not be permitted to rely on the plan's prior approval rule where the medical necessity of the surgery was admitted. The court held that:

 
When the trustees have consistently and literally followed an unambiguous benefit eligibility requirement that was bargained for and that was set forth in an employee benefit plan, that action cannot be called arbitrary and capricious by a ...

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