United States District Court, W.D. Pennsylvania
October 13, 2005.
KERRY A. McQUISTIAN, Plaintiff,
METROPOLITAN LIFE INSURANCE COMPANY, Defendant.
The opinion of the court was delivered by: GARY LANCASTER, District Judge
Before the court are the parties' cross motions for summary
judgment. This is a claim for disability benefits under ERISA,
29 U.S.C. § 1132(a) (1) (B). Plaintiff appeals defendant's denial of
long term disability benefits, arguing that defendant acted in an
"arbitrary and capricious" manner and abused its discretion by
denying plaintiff's claim. Defendant claims to have acted within
its discretionary authority to determine eligibility for benefits
and to construe the terms of the long term disability plan at
Both parties have filed motions for summary judgment under
Fed.R.Civ.P. 56(c), arguing that there are no issues of material
fact. Plaintiff claims that defendant, as both fiduciary and
administrator of the long term disability plan, abused its
discretion in denying plaintiff's claim for extended disability
benefits. To the contrary, defendant argues that it is entitled to summary judgement because its interpretation of the long term
disability plan and the terms therein was reasonable.
For the following reasons, defendant's motion for summary
judgment will be GRANTED and plaintiff's motion for summary
judgment will be DENIED.
Unless otherwise indicated, the following material facts are
Plaintiff is a former employee of Praxair, Inc. As a result of
his employment, he was a participant in Praxair's long-term
disability plan (the "Plan"). Defendant Met Life served as the
claims administrator for the Plan.
Plaintiff began his employment with Praxair in 1991 as a tool
and die maker. He stopped working on June 14, 1998 due to a
diagnosis of major depressive disorder. On December 16, 1998,
defendant approved plaintiff's application for benefits.
According to the Plan, benefits for disability due to mental
illness are limited to 24 months unless the participant is
confined to a legally certified hospital or continues to be a
participant in an "approved managed mental health care program."
On October 10, 2000, defendant notified plaintiff that because he
was not a participant in a managed mental health care program,
his benefits would expire on December 15, 2000. In an effort to keep his benefits from expiring, on December 4, 2000, plaintiff
submitted a psychiatric evaluation and five appointment slips
from his treating psychiatrist as proof that he was being treated
through Allegheny East Mental Health/Mental Retardation. On
January 2, 2001, defendant notified plaintiff that the documents
plaintiff supplied failed to demonstrate that he was a
participant in an approved managed mental health care program.
Plaintiff then brought this ERISA action to challenge the
Administrator's decision under 29 U.S.C. § 1132(a) (1) (B), which
allows an ERISA plan participant to bring a civil action to
recover benefits under the terms of the Plan.
II. STANDARD OF REVIEW
A. The Summary Judgment Standard
Fed.R.Civ.P. 56(c) provides that summary judgment may be
granted if, drawing all inferences in favor of the non-moving
party, "the pleadings, depositions, answers to interrogatories,
and admissions on file, together with the affidavits, if any,
show that there is no genuine issue as to any material fact and
that the moving party is entitled to a judgment as a matter of
law." Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 247 (1986)
(internal quotation marks omitted). Further, because the instant
case is a review of an administrative decision, it is appropriate
for summary disposition. Couzens v. Equitable Life Assurance Society of the United States, No. Civ. A. 98-527, 1998 WL
695425 (E.D. Pa. Oct. 2, 2005).
The mere existence of some factual dispute between the parties
will not defeat an otherwise properly supported motion for
summary judgment. Anderson, 477 U.S. at 247-48. A dispute over
those facts that might affect the outcome of the suit under the
governing substantive law, i.e., the material facts, however,
will preclude the entry of summary judgment. Id. at 248.
Similarly, summary judgment is improper so long as the dispute
over the material facts is genuine. In determining whether the
dispute is genuine, the court's function is not to weigh the
evidence or to determine the truth of the matter, but only to
determine whether the evidence of record is such that a
reasonable jury could return a verdict for the nonmoving party.
B. The Arbitrary and Capricious Standard Under ERISA
When, as here, a plan administrator has the discretionary power
to construe the terms of a plan or to determine who is eligible
for benefits, the court will review the administrator's decision
according to an "arbitrary and capricious" standard. See
Stoetzner v. United States Steel Corp., 897 F.2d 115, 119 (3d
Cir. 1990). Under the arbitrary and capricious standard, the
court will overturn an administrator's decision only if it is
"`without reason, unsupported by substantial evidence or erroneous as a matter of law.'"
Abnathya v. Hoffmann-La Roche, Inc., 2 F.3d 40, 45 (3d Cir.
1993) (citations omitted). The court's review is narrow; "`the
court is not free to substitute its own judgment for that of the
[administrator] in determining eligibility for plan benefits.'"
Id. (citation omitted). Therefore, the court will not disturb
an administrator's interpretation "if reasonable." See
Firestone Tire and Rubber Co. v. Bruch, 489 U.S. 101, 111
(1989). The court will accept that an administrator acted
reasonably if the administrator "examine[s] the relevant data and
articulate[s] a satisfactory explanation for its action including
a `rational connection between the facts found and the choice
made.'" Motor Vehicle Mfrs. Ass'n v. State Farm Mut. Auto.
Ins. Co., 463 U.S. 29, 43 (1983) (citation omitted).
Plaintiff argues that per the Court of Appeals' decision in
Pinto v. Reliance Standard Ins. Co., 214 F.3d 377 (3d Cir.
2000), we must apply a heightened form of the arbitrary and
capricious standard of review when an insurance company both
funds and administers the benefits at issue because the company
is generally acting under a conflict of interest. While we
acknowledge that in Pinto, the Court of Appeals adopted a
"sliding scale approach," in which district courts must "consider
the nature and degree of apparent conflicts with a view to
shaping their arbitrary and capricious review of benefits determinations of discretionary decisionmaker," we find the
approach inapplicable here. See Pinto, 214 F.3d at 393. The
appropriate standard of review in this case is the arbitrary and
capricious standard because no conflict of interest exists. That
is, defendant was not financially responsible for the payment of
claims when plaintiff's request for extended benefits was denied.
Even assuming arguendo that a conflict exists so as to warrant
the application of a heightened form of the arbitrary and
capricious standard, we still hold that defendant's denial of
long term benefits was reasonable.
Congress passed ERISA in order "to promote the interests of
employees and their beneficiaries in employee benefit plans."
Dewitt v. Penn-Del Directory Co., 106 F.3d 514, 520 (3d Cir.
1997). The statue is focused on the administration of benefit
plans, as opposed to the precise design of the plans themselves.
The Court of Appeals has made clear that, "the award of
benefits under any ERISA plan is governed in the first instance
by the language of the plan itself." Id. A court must uphold an
administrator's interpretation of a plan, even if it disagrees
with it, so long as the administrator's interpretation is
rationally related to a valid plan purpose and is not contrary to the plain language of the plan." Id. Thus, in determining
whether the plan administrator's decision to deny plaintiff's
long term disability benefits was arbitrary and capricious, we
look to the Plan itself. The law requires an ERISA plan
administrator to "discharge his duties with respect to a plan . . .
in accordance with the documents and instruments governing the
plan insofar as such documents and instruments are consistent
with the provisions of [ERISA]." 29 U.S.C. § 1104(a) (1) (D).
There are two relevant provisions of the Plan at issue here.
First, under the section entitled, "Duration of Benefits," the
Generally, benefits payable for total disabilities
resulting from mental and nervous disorders . . . are
limited to no more than 24 months unless:
you are confined in a legally certified hospital
approved for the treatment of such conditions; or,
you continue to be a participant in an approved
managed mental health care program.
Second, the Plan affords defendant discretionary authority as
In carrying out their responsibilities under the
Plan, the Plan Administrator and other Plan
fiduciaries shall have full discretionary authority
to interpret the terms of the Plan and to determine
eligibility for entitlement to Plan benefits in
accordance with the terms of the Plan. An
interpretation or determination made pursuant to such
discretionary authority shall be given full force and
effect, unless it can be shown that the interpretation or
determination was arbitrary or capricious.
Taken together, the Plan affords defendant full discretion in
determining "whether plaintiff was a participant in an approved
managed mental health care program." We find that a reasonable
jury could not conclude that defendant abused its discretion when
it denied plaintiff's request for continued long term disability.
In a letter dated February 7, 2003, defendant made clear to the
plaintiff its interpretation of the term "approved mental health
It is Met Life's interpretation that an "Approved
Mental Health Care Program" is a structured treatment
plan of order, consisting of an intake evaluation
with the setting of clearly identifiable
goals/treatment protocols and an anticipated discharge
date (e.g. intensive outpatient program, transitional
living program). Generally these programs follow an
inpatient confinement related to the same condition
while providing a continuation of the intensive
treatment required by the patient's condition.
Defendant reasonably concluded that plaintiff's evidence did not
demonstrate clearly identifiable goals, treatment protocols or an
anticipated discharge date. Defendant acted reasonably and within
its discretionary authority in making its determination to deny
plaintiff disability benefits in excess of 24 months.
As such, defendant's decision that plaintiff was not enrolled
in an appropriate, approved plan was well within its discretion,
and defendant's conduct does not rise to the level of being arbitrary or capricious as a matter of law. That is,
defendant's denial of benefits was not, "without reason,
unsupported by substantial evidence or erroneous as a matter of
law." See Abnathya, 2 F.3d at 45.
Because plaintiff has not demonstrated that a genuine dispute
of material fact exists as to whether defendant's denial was
arbitrary and capricious, defendant is entitled to summary
Defendant's motion for summary judgment will be granted. The
appropriate order follows. ORDER
Accordingly, this 13th day of October, 2005, upon consideration
of the parties' cross motions for summary judgment, IT IS HEREBY
ORDERED that defendant's motion [document #13] is GRANTED.
Plaintiff's motion for summary judgment [document #11] is DENIED.
The Clerk of Court is directed to mark this case closed.
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