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Abnathya v. Roche

argued: April 28, 1993.

ALINE ABNATHYA, APPELLEE
v.
HOFFMANN-LA ROCHE INC., A CORPORATION OR BUSINESS ORGANIZATION; JOHN DOE, SAID NAME BEING FICTITIOUS; JAMES SMITH, SAID NAME BEING FICTITIOUS; HENRY JONES, SAID NAME BEING FICTITIOUS HOFFMANN-LAROCHE INC., APPELLANT



On Appeal From the United States District Court For the District of New Jersey. (D.C. Civ. No. 91-02242).

Before: Becker, Hutchinson, and Weis, Circuit Judges.

Author: Becker

Opinion OF THE COURT

BECKER, Circuit Judge.

Aline Abnathya, a former employee of defendant Hoffmann La Roche Inc., brought this suit challenging Hoffmann's decision to discontinue her long-term disability benefits. Concluding that Hoffmann's decision was arbitrary and capricious, in violation of the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. § 1001 et seq. (1988), the district court granted summary judgment in favor of Abnathya. Because Hoffmann's Long-Term Disability Benefits Plan ("the LTD Plan") gives Hoffmann, as plan administrator, the discretion to make eligibility determinations under the Plan, the district court correctly applied the deferential arbitrary and capricious standard of review required under Firestone Tire and Rubber Co. v. Bruch, 489 U.S. 101, 115, 109 S. Ct. 948, 956-57, 103 L. Ed. 2d 80 (1989). However, we find no support in the record for the court's Conclusion that Hoffmann's decision was arbitrary and capricious. Rather, the record clearly demonstrates the contrary.

Under the arbitrary and capricious standard, the court must defer to the administrator of an employee benefit plan unless the administrator's decision is clearly not supported by the evidence in the record or the administrator has failed to comply with the procedures required by the plan. Hoffmann's determination that Abnathya was no longer totally disabled within the meaning of the LTD Plan is clearly supported by the evidence in the record, and there is no evidence that Hoffmann failed to comply with any of the procedures required under the Plan. Hence we will reverse the grant of summary judgment in favor of Abnathya and will order that summary judgment be entered in favor of Hoffmann.

I.

Hoffmann maintains a self-funded employee benefits plan which includes the Long-Term Disability Benefits Plan. The LTD Plan is an employee welfare benefit plan governed by ERISA. See ERISA § 3(1), 29 U.S.C. § 1002(1) (1988). The Plan provides benefits beginning after 182 consecutive days of "total disability," which is defined by the Plan as occurring where

(a) for the [first two years during which benefits are received] the Member is completely unable to perform any and every duty of his regular occupation and is not engaged in any occupation or employment for wage or profit; and (b) for the period commencing twenty-four months after [benefits are first received] the Member is completely unable to perform any and every duty of any gainful occupation for which he is or becomes reasonably qualified by training, education or experience.

Hoffmann acts as the claims administrator for the LTD Plan. The Plan authorizes a committee, whose members are appointed by Hoffmann's Board of Directors, to make all determinations regarding a claimant's eligibility for and entitlement to LTD Plan benefits.*fn1 Specifically, the Plan provides:

The Committee shall have . . . the power to interpret and construe the Plan, to direct payment of benefits and to determine all questions relating to eligibility for membership, eligibility for disability income benefits, and computation of benefits, and all similarly related matters necessary or advisable to operate and administer the Plan. The Committee's determination of all questions arising under the Plan shall be binding upon all employees, Members and any others concerned.

The Plan further provides that participants receiving LTD benefits may be required to undergo semi-annual medical examinations by a physician appointed by the Committee and/or to submit evidence to the Committee of continued total disability; if the Committee determines that a participant is no longer totally disabled, Hoffmann will cease paying LTD benefits.*fn2 The participant may appeal a decision to discontinue benefits by requesting in writing that the Committee review the decision. The second determination by the Committee becomes final.

Abnathya worked for Hoffmann as a data entry operator from October of 1967 until approximately September 20, 1985. She had contracted polio as a child, which permanently paralyzed her left leg, requiring that she wear a full brace and that she walk with a cane. Over the years at her job at Hoffmann, she developed severe pain in her neck, shoulders, arms, hands, and legs from having to sit for long periods of time. In February of 1986, claiming that she suffered from a totally disabling orthopedic condition, Abnathya applied for LTD Benefits.

As support for her claim, Abnathya submitted a report, dated February 6, 1986, from Dr. Andre Birotte, an orthopedic surgeon who was her attending physician. Dr. Birotte described Abnathya's symptoms as "severe pain in the left ankle and right knee and right hand." His diagnosis was "probable degenerative joints disease of the lumbosacral spine and hips; bilateral flaccid paralysis secondary to poliomyelitis." He concluded that Abnathya was "totally disabled for any gainful employment." Abnathya had also been examined in January of 1986 by Dr. Albin Leonhardt, an orthopedic surgeon selected by MetLife, see supra n.1, who similarly ...


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