United States District Court, M.D. Pennsylvania
For Jason Jabara, Plaintiff: Kevin M. Walsh, LEAD ATTORNEY, Kingston, PA.
For Aetna Life Insurance Company, Defendant: John G. Dean, Elliott Greenleaf & Dean, Scranton, PA; Melissa M. Weber, Elliott Greenleaf & Siedzikowski, Blue Bell, PA.
Robert D. Mariani, United States District Judge.
Presently before the Court is " Plaintiff's motion to determine the appropriate standard of review" (Doc. 17) in this Employee Retirement Income Security Act (" ERISA") action for long-term disability benefits. ( See Compl., Doc, 1, at ¶ ¶ 4-5). Plaintiff Jason Jabara has filed briefs in support of his motion (Docs. 18, 28), Defendant Aetna Life Insurance Company (" Aetna") has filed a brief opposing the motion (Doc. 22), and the matter is ripe for disposition.
The Complaint alleges Plaintiff had long-term disability insurance through his employment at the Tobyhanna Army Depot. (Doc. 1 at ¶ 3). Aetna administered his policy. (Id.). Jabara received benefits under the policy between February 2, 2011 and February 2, 2013. (Id. at ¶ 6). On February 2, 2013, Aetna terminated Jabara's benefits due to an alleged lack of medical evidence. (Id.). Plaintiff filed an administrative appeal and allegedly provided Aetna with " extensive medical evidence of his disability." ( See id. at ¶ ¶ 8-9). On May 24, 2013, Aetna sent Plaintiff a letter indicating it would not reinstate his benefits, (Id. at ¶ 9).
Jabara then filed the instant action seeking reinstatement of his long-term disability benefits pursuant to ERISA, 29 U.S.C. § 1132(a)(1)(B). (Id. at ¶ ¶ 5, 9). In his motion, Jabara asks the Court to determine the appropriate standard of review. (Doc. 17). Aetna asserts that its denial of Jabara's benefits is subject to review under an arbitrary and capricious standard. (Id. at ¶ 5). Plaintiff submits that de novo review should apply, (Id.).
The parties have included for the Court's review the " Group Life and Accident and Health Insurance Policy" (" Group Insurance Policy") and a " Booklet-Certificate" (collectively the " Plan"). The " Booklet-Certificate is part of the Group Insurance Policy between Aetna Life Insurance Company and the Policyholder." (Plan at 1). As discussed below, the Booklet-Certificate " is the Summary Plan Description ['SPD'] required by ERISA." (Id. at 29). The Booklet-Certificate indicates that Defense Support Services LLC is the Group Policyholder and Plan Administrator. (Id. at 3, 29). It further states, " The Group Insurance Policy determines the terms and conditions of coverage." (Id. at 3).
Under the " General Provisions" section, the Group Insurance Policy states:
Claim Determinations; ERISA Claim Fiduciary, For the purpose of section 503 of . . . (ERISA), [Aetna is] a fiduciary with complete authority to review all denied claims for benefits under this Policy. This includes, but is not limited to, the denial of certification of the medical necessity of hospital or medical treatment. In exercising such fiduciary responsibility, [Aetna] shall have discretionary authority to determine whether and to what extent eligible employees and beneficiaries are entitled to benefits and to construe any disputed or doubtful terms under this Policy, the Certificate or any other document incorporated herein. [Aetna has] the right to adopt reasonable policies, procedures, rules, and interpretations of this Policy to promote orderly and efficient administration.
(Plan at 73 (emphasis omitted)).
" The Supreme Court has held that 'a denial of benefits challenged 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.'" Viera, 642 F.3d at 413 (quoting Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115, 109 S.Ct. 948, 103 L.Ed.2d 80 (1989) (alteration in Viera )). " If the plan gives the administrator or fiduciary discretionary authority to make eligibility determinations, " courts " review its decisions under an abuse-of-discretion (or arbitrary and capricious) standard." Id. " 'Whether a plan administrator's exercise of power is mandatory or discretionary depends upon the terms of the plan.'" Id. (quoting Luby v. Teamsters Health, Welfare, & Pension Trust Funds, 944 F.2d 1176, 1180 (3d Cir. 1991)). Discretionary power can be granted expressly or impliedly, and " [t]here are no 'magic words' determining the scope of judicial review[.]" Id. If the plan is ambiguous, ...