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Barry Frey v. Herr Foods Inc. Employee Welfare Plan

December 12, 2012

BARRY FREY,
v.
HERR FOODS INC. EMPLOYEE WELFARE PLAN



The opinion of the court was delivered by: Surrick, J.

MEMORANDUM

Presently before the Court is Plaintiff's Motion for Confirmation of the Appropriate Standard of Review (ECF No. 7). For the following reasons, Plaintiff's Motion will be granted.

I. BACKGROUND

A. Procedural History

Plaintiff filed an Employee Retirement Income Security Act of 1974 ("ERISA") claim against Defendant in the Court of Common Pleas of Chester County, Pennsylvania. (Compl., ECF No. 1 Ex. A.) On March 1, 2011, Defendant removed the case to this Court. (Notice of Removal, ECF No. 1.) Defendant filed an Answer on March 9, 2011. (ECF No. 3.) On April 4, 2011, Plaintiff filed a Motion To Determine The Courts Standard Of Review and a Brief in support thereof. (Pl.'s Mem., ECF Nos. 7, 8.) On May 12, 2012, Defendant filed a Response. (Def.'s Mem., ECF No. 13.)

B. Factual Background

Plaintiff was employed by Herr Foods, Inc. as a Peeling Room Operator until he ceased work on or about December 18, 2009. (Joint Case Report ("JCR") 1, ECF No. 6.) As an employee, Plaintiff was a participant in the Herr Foods Inc. Employee Welfare Plan (hereinafter the "Plan"). (Id.) Metropolitan Life Insurance Company ("MetLife") is the claims administrator for the Plan. (Id.)

In July 2009, Plaintiff experienced a right thalamic lacunar infarct in his brain, commonly known as a stroke, and suffered from numbness and weakness on the left side of his body. (Id.) In addition, Plaintiff suffers from severe neck pain and limited range of motion, due to cervical spine degenerative disease, along with hypertension and depression. (Id. at 1-2.) Defendant asserts that "Plaintiff's hypertension was controlled, his depression was mild, and the cervical spine degeneration findings were reported as minimally changed compared to his study from 2001, after which time he had been working." (Id. at 3.) On six different occasions in 2010, Plaintiff's physician, Daniel Diehl, M.D., determined that Plaintiff was disabled as a result of his physical condition and that improvement was not expected. (Id. at 2.) Despite this determination, Dr. Diehl did not require Plaintiff to engage in physical or occupational therapy. (Id. at 3.)

On April 17, 2010, a nurse case manager assigned to Plaintiff's disability claim advised that additional medical information was needed to determine whether Plaintiff was disabled. (Id. at 2.) Without obtaining additional information, a claims specialist decided on April 22, 2010 that the existing medical record did not support a disability determination. (Id.) On April 28, 2010, the claims specialist denied Plaintiff's disability claim. (Id.) Plaintiff appealed the denial of benefits. (Id.)

After the denial, Defendant issued a peer review report that concluded that the effects of Plaintiff's stroke did not preclude him from returning to work. (Id.) Defendant further determined that Plaintiff's neck pain and cervical spine degenerative disease were not uncommon with aging, and would not prevent him from carrying out his work duties. (Id.) In making its determination, Defendant did not consider the level of pain Plaintiff was experiencing, nor did it explain why Dr. Diehl's medical opinion was rejected. (Id.)

We are asked to review Defendant's denial of Plaintiff's disability claim and to determine whether Plaintiff is entitled to benefits. (Compl.) We must first determine the appropriate standard of review. Since the parties filed their submissions, the Supreme Court and the Third Circuit have provided additional guidance on the issue before us. See CIGNA Corp. v. Amara, 131 S.Ct. 1866 (2011); Viera v. Life Ins. Co. of N. Am., 642 F.3d 407 (3d Cir. 2011).

II. LEGAL STANDARD

A claim challenging the denial of benefits under ERISA "is to be reviewed under a de novo standard unless the benefit plan gives the administrator or fiduciary discretionary authority to determine eligibility for benefits or to construe the terms of the plan." Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989). An abuse-of-discretion or arbitrary and capricious standard applies when the plan terms grant "the administrator or fiduciary discretionary authority to make eligibility determinations . . . ." Viera, 642 F.3d at 413.*fn1

Ambiguous language in a plan is interpreted in favor of the insured. Id. (citing Heasley v. Belden & Blake Corp., 2 F.3d 1249, 1258 (3d Cir. 1993)). Moreover, the burden of demonstrating that the abuse-of-discretion standard applies lies with the plan administrator. Id. Although summary documents provide communication with beneficiaries about the plan, "their statements do not themselves constitute the terms of the plan" ...


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