BROWN v. FIRST RELIANCE STANDARD LIFE INSURANCE CO., No. 2:2010cv00486 - Document 31 (W.D. Pa. 2011)
Court Description: MEMORANDUM OPINION re: 18 MOTION for Summary Judgment filed by Defendant FIRST RELIANCE STANDARD LIFE INSURANCE CO., and 22 Cross MOTION for Summary Judgment filed by Plaintiff, JULIE BROWN. Signed by Judge William L. Standish on 3/17/2011. (md) Modified on 3/18/2011. (md)
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IN THE UNITED STATES DISTRICT COURT FOR THE WESTERN DISTRICT OF PENNSYLVANIA JULIE BROWN, Plaintiff, vs. Civil Action No. 10-486 FIRST RELIANCE STANDARD LIFE INSURANCE COMPANY, Defendant. MEMORANDUM OPINION Pending before the Court are cross motions for summary judgment filed by Defendant First Reliance Standard (Doc. No. 18) and P seeks fe Insurance Company intiff Julie Brown (Doc. No. 22.) short-term disability benefits under an Plaintiff employee welfare fi t plan governed by the Employee Retirement Income Security Act of 1974, 29 U.S.C. scussed below, § 1001, et seq. ("ERISA.") For reasons aintiff's Motion is denied and Defendant's Motion is granted. I. INTRODUCTION A. Factual Bac round 1 From December 27, 2004, through at least November 9, 2007, intiff Julie Brown was employed as a machine operator at National 1 The facts in this section are undisputed, based on the Court's reading of Defendant's Concise Statement of Material Facts, Doc. No. 20; the Appendix thereto, Doc. No. 21; Plaintiff's Concise Statement of Material Facts, Doc. No. 24; and Plaintiff's Response to Defendant's Concise Statement of Facts, Doc. No. 25. Envelope Corporation Pennsylvania. ("National"), National disability benefits maintained by provided ("the Defendant located Plan") First Company ("First Reliance.") its under Reliance in Fayette employees a policy Standard County, short-term offered Life and Insurance Ms. Brown was enrolled in the Plan as of November 2007. At the time of the events approximately 45 years old. in question, Ms. Record, Doc. No. 21, "AR," at 92.) but after an was She had previously given birth to four children; a fifth pregnancy ended in miscarriage. ligation, Brown (Administrative She had then undergone a tubal unsuccessful attempt to reverse that procedure, she began consulting in June 2006 with Dr. Anthony Wakim, a fertility specialist at Magee Women's Hospital Pennsyl vania. in vitro in Pittsburgh, Ms. Brown then decided that she wanted to proceed wi th fertilization ("IVF.") 2 In October 2007, Dr. Wakim described Ms. Brown's prognosis for such a pregnancy as "very poor." (AR at 1 0 9 , III , 113 , 11 6 . ) 3 In vitro fertilization "is an assisted reproductive technology that involves administration of fertility drugs to the woman, surgical extraction of her eggs, fertilization in a laboratory, and surgical implantation of the resulting embryos into the woman's womb. Each IVF treatment takes weeks to complete, and multiple treatments are sometimes needed to achieve a successful pregnancy." Hall v. Nalco Co., 534 F.3d 644, 645-646 (7th Cir. 2008), ci ting The Merck Manual of Medical Information, 1418-19 (Mark H. Beers, MO, et al. eds., 2d home ed. 2003), and the Mayo Clinic Family Health Book, 1069-70 (Scott C. Litin, MO, ed., 3d ed. 2003). 3 In the administrative record, Ms. Brown is also referred to as "Julie 2 In the 11 of 2007, Ms. Brown underwent a number of tests and examinations in preparation working until Friday, the IVF procedure. November 9, 2007. She continued Between November 12 and November 26, Ms. Brown visited the Magee Clinic several times for sonograms, blood tests and physical examinations, culminating in a surgical procedure implantation of for the removal of rtilized egg Plaintiff subsequently learned that an egg on November on November the 26. 23 and (AR 106.) IVF procedure had been successful and she was pregnant. Meanwhile, on November 19, short-term disabili ty (" STD") Ms. Brown submitted a claim for benefits under the Plan. In her claim, her employer stated that the reason Ms. Brown had stopped work as of November 9, 2007, was "in vitro fertil ization. " an Attending Physi (AR183.) In an's Statement submitted with the claim, Wakim indicated that Ms. Brown would not be able to per Dr. rm her job beginning on November 12, 2007, through at least December 14, 2007, and possibly longer depending on "pregnancy testing following IVF." (AR 184.) On December 18, 2007, return to work but restrict Plaintiff's physician released her to her to work which required no heavy lifting (i.e., no more than 10 pounds) and no continuous standing. (AR 103.) Sandoval lf Ms. Brown attempted to return to work as of that date, and "Julie Sandoval Brown." 3 learned rest that r employer ctions and she was laid-off. On January 18, 2008, could not accommodate these (AR 42.) rst Reliance notified Ms. Brown that it was denying her claim for combination of reasons. short-term disability benefits for a First, under the terms of the insurance policy between National and First Reliance, undergoing in vitro ilization was not considered a "Sickness" or "Injury," as those terms were defined. submitted in Secondly, the medical records Ms. support reflected any s ef of her application r benefits had not cts from the treatment which would have prevented her from working as of November 12, 2007. Al though the letter from First Reliance advi to have this decision Brown had (AR 68-69.) Ms. Brown of her right ewed, she did not request Defendant to do so at that time. On May 6, 2008, Ms. Brown filed a second claim for benefits, identifying her condition as pregnancy and disability began as of November 12, 2007. in indicating that her According to the medical records provided by her obstetrician, Dr. James Nolfi, in support of this claim, her anticipated delivery date would be August 15, 2008, and she would be able to return to work on September 29, 2008. In the interim, she was still restricted from any work which required continuous standing or lifting more than 10 pounds. Among Dr. Nolfi's records was an undated, unsigned document which i 4 cated Plaintiff could perform "no heavy lifting" and was unable to perform "continuous standing." Her serious health condition was described as pregnancy and the form noted that "IVF treatment resulted in pregnancy." A (AR 102; 152-153.) days later 18, 2008 I on May 16, 2008, Ms. Brown appealed the January ial of benefits, stating that her "conscious decision" to become pregnant "should have nothing to do with the decision of eligibil y of benefi ts. (AR 85. ) II mentioned negative side ef She also contended that she had cts of the IVF treatment to her nurse drug monographs provided by her pharma and atta underl st in which she the side effects she had experienced. At this internal point, First iance undertook (AR 87-91.) a comprehensive ew of Plaintiff's entire claim file and provided the file to an independent specialist in obstetrics and gynecology, Dr. Rafat A. Abbasi. reflect (AR 57-58.) Ms. Brown had had an "uneventful p without problems or incident. and no complications noted. 71.) ~no restrictions and 1 that the record ss. She did IVF There was no hyperstimulation noted There were no side effects noted. He commented that bas records." Dr. Abbasi on his review of t tat ions are suppo II (AR documentation, according to the (AR 71.) Based on these reviews, rst Reliance again informed Ms. Brown on June 12, 2008, that it had concluded she was not disabled at the 5 time she had stopped working and that her initial claim for benefits was again denied. Moreover, because she was not actively at work when she became pregnant, and thus not in an "Eligible Class" National employees covered by the Plan, her second request for short term disability coverage beginning with the IVF and throughout the course of her pregnancy was also denied. (AR 57 61.) After her baby was born, Ms. Brown returned to work at National until she voluntarily Ie Doc. No. 22, Exh. 1.) 4 in May 2009. (Affidavit of Julie Brown, Ms. Brown did not appeal the decision of June 12, 2008, denying her second application for benefits, inasmuch as First Reliance stated in that letter that she had exhausted her administrative remedies available under the Plan. B. (AR 60.) Procedural Background Having exhausted her administrative appeals with First Reliance, aintiff filed suit in this Court on April 14, 2010. her one count complaint, aintiff claims that In rst Reliance abused its discretion for a number of reasons in denying her request for short-term disability benefits while undergoing IVF treatments and Under most circumstances, "the record for arbitrary-and-capricious review of ERISA benefits denial is the record made before the plan administrator, and cannot be supplemented during litigation." Kosiba v. k & Co. 384 F.3d 58, 67 n.5 (3d Cir. 2004) i Po v. Hartford Ins. Co. 501 F.3d 154, 168 (3d Cir. 2007) (in deciding summary judgment in an ERISA denial case, the court is generally limited to the facts known to the plan administrator at the time the decision was made.) The Court has not considered the statements made by Ms. Brown in her affidavit as evidence, but rather provides this information only to complete the factual account. 6 during the resulting pregnancy. lowing unsuccessful mediation in July 2010, filed pending cross motions brie II. the issues. r the parties summary judgment and fully matter is now for decision by the Court. JURISDICTION AND VENUE parties that jurisdiction pursuant 1132 (a) (1) (b) and this 28 U.S.C. to (e) (I). Court § 1331 subject and 29 matter U.S.C. §§ Venue is properly laid in the Western District of Pennsylvania inasmuch as t occurred within this has strict. alleged ERISA See 29 U. S.C. § olations 1132 (e) (2). III. STANDARD FOR SUMMARY JUDGMENT A court may grant summary judgment if the party so moving can show"t moving re is no genuine issue as to any material fact and that the party Fed.R.C is entitled to judgment as a matter of law. ff .P. 56{c) i Sollon v. Ohio Cas. Ins. Co., 396 F. Supp.2d 560, 568 (W.O. Pa. 2005). If a reasonable jury could return a verdict for the non-movant, the di the di A factual would af e is genuine and if, under substantive law, ct the outcome of the suit, it is material. dispute between the parties t is both genuine and material will defeat a motion for summa judgment. Anderson v. Liberty Lobby, (1986). Inc., 477 U.S. 242, 247-248 In considering a motion for summary judgment, the court must view all evidence in the light most favorable to the non-movant, 7 accept the non-movant's version of the facts as true, and draw all reasonable inferences and resolve any conflicts in its favor. Sollon, id., ci ting Matsushi ta Elec. Indus. Co. Ltd. v. Zenith Radio Corp., 475 u.s. 574, 587 (1986), and Big Apple BMW, Inc. v. BMW of North America, Inc., 974 F.2d 1358, 1363 (3d Cir. 1992). In short, the movant must show that if the pleadings, depositions and other evidentiary material were admissible at trial, the other party could not carry its burden of proof based on that evidence and a reasonable jury would thus decide all genuine material disputes in the movant's favor. Celotex Corp. v. Catrett, 477 U.S. 317, 318 (1986). Once the movant has demonstrated that there are no genuine issues of material fact, the burden shifts to the non-moving party to "make a showing sufficient to establish the existence of every element essential deposi tions Sollon, to his case, and admissions id.; Fed.R.Civ.P. on based on Celotex, file." The 56(e). the sum of affidavits or by id. at 322-323; the affirmative evidence to be presented by the non-moving party must be such that a reasonable jury could find in its favor, and it cannot simply reiterate unsupported assertions, conclusory allegations, or mere suspicious Liberty beliefs. Township of Manalapan, This Court may concurrently. Lobby, 47 F.3d 628, resolve id. 633 at 250-252; Groman v. (3d Cir. 1995). cross motions for summary judgment See InterBusiness Bank, N.A. v. First Nat'l Bank of 8 Mifflintown, 318 F. Supp.2d 230, 235 (M.D. Pa. ting 10 2004), Charles A. Wright et ai., Federal Practice and Procedure § 2720 (3d ed. 1998.) When doing so, independently and must the court must consider each motion ew the evidence in the light most favorable to the non-moving party with respect to each motion. Pichler v. Unite, 542 F.3d 380, 386 (3d Cir. 2008); _C_I____~___v_~.__ F_i~r~s~t~~_i~o~n Health Plan of New Jersey, 208 F. Supp.2d 463,468-469 (D. N.J. 2002). "A party's concessions made for purposes of its own summary judgment motion do not carryover into the court's consideration of the opposing party's motion." LaManna v. Special Agents Ass'n, 546 F. Supp.2d 261, 267 (W.O. Pa. 2008), Mut~ Benefits citing Coolspring Stone Supply, Inc. v. Am. States Life Ins. Co., 10 F.3d 144, 150 (3d Cir. 1993). The question of whether the defendant is entitled to judgment as a matter of law under the standards courts apply when determining if benefits protected by ERISA have been wrongfully denied is one the courts resolution. have found Muller v. particularly rst Unum well-suited for summary fe Ins. Co., 341 F.3d 119, 124 ---~----------~-----. (2d Cir. 2003) (Because there is no right to a jury tr ial under ERI SA, the dist ct court typically acts as the finder of fact and conducts a bench trial "on the papers.") 9 IV. ANALYSIS A. The Part s In its motion summary judgment, Defendant argues that under the terms and definitions governing the Plan, Ms. Brown was not elig e for benefits at the time she Ie her employment on November 9, 2007, because undergoing IVF treatments was ne "Sickness" nor provisions. "Injury" Her covered subsequent by the pregnancy, short-term which First r a benefits Reliance concedes would have been covered under the "Sickness" provisions of the Plan, employed" was not when covered because Ms. she became therefore not eligib pregnant Brown was in for coverage. late not November "actively 2007 and Under established Supreme Court and Third Circuit precedent, where the ERISA-covered plan question gives authority, eligibility the scretion such for administrator benefits, of the encompasses as plan the occurred discretionary determination reo Because of the administrator of the plan acted consistently with the unambiguous terms of the Plan and within its discretion in denying benefits, summary judgment must (Defendant's Motion be granted in favor Summary Judgment, ~ of 10, Ins. Co. v. Glenn, 554 U.S. 105 (2008), and Schwing First Reliance. ting Metro. Life V. Lilly Health Plan, 562 F.3d 522 (3d Cir. 2009).) Conversely, Plaintiff argues that substantial evidence appears 10 in the admi strative record to support her position that IVF "procedure" actually and inj ections on began November 12, with 2007, implantation, November 26, 2007. a series not of the date of fore, the 1 her physicians imposed effectively caused of the examinations t actual tat ions which to become sabled as ior date, first because her physician required her to be f from work during the two weeks prior to the fertilization, then, after she was allowed to return to work, r employer could not provide the light work to which she was limited. (Plaintiff's Brief in Support of Motion for Summary Judgment, Brief, II 3-4.) Doc. No. 23, "Plf.' s Second, Defendant acted arbitrarily and capriciously in making its decision rding her second application by refusing to accord any weight to the Medical Certification Statement required by National because it was not signed, even though it was obvious from the face of the document that it was generated by the Magee Clinic. Moreover, the letter of June 12, 2008, denying the appeal of the first application and her second claim for benefits, was the first time Plaintiff had been apprised that this was among the reasons for denying her claim, far too long after she could have taken any steps to rectify the omission of a signature. (Id. 10-11. ) Ms. Brown also argues that First Reliance's refusal to allow her to remediate the deficiencies which were the basis for the denial -- but were first made known to her in the letter of June 12, 2008 11 violates the ERISA p sions which require benef provide adequate notice to the plan beneficiaries. at 11-14.) Fourth, she (PIt.' s ef s that the Plan language is not only vague but violates the al standard of care imposed by ERISA upon a plan administrator to dis of the participant and plans to its duties solely in the interests neficia nally, Ms. Brown contends t es of a plan. (Id. at 14-19.) rst Reliance ignored substantial evidence supporting her claim when it refused to acknowledge she was legitimately limited to only light duty work owing to the risks inherent in her IVF treatments and subsequent pregnancy. (Id. at 19 23.) B. ERISA permits a or beneficiary of an insurance i plan covered by ERISA to bring a civil suit "to recover benefits due to him under the terms of his plan, to enforce his rights under t term of the plan, or to clari the terms of the plan." his rights to future benefits under 29 U.S.C. States Court of Appeals for t § 1132 (a) (1) (B). As the Third Circui t pointed out in _M_i-ct,--_l_l v. Eastman Kodak Co., 113 F.3d 433,437 (3d Cir. 1997), ERISA itself does not establish the standard of review for an action brought under § 1132 (a) (1) (B). In Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989), the Supreme Court held that "a denial of bene challenged under § 1132 (a) (1) (B) is to be reviewed under a 12 ts novo standard unless the benefi t plan gives the administrator or fiduciary discretionary authority to determine eligibility for benefits or to construe the terms of the plan." If, however, the plan does provide the administrator with di scretionary authority, review is more deferential, and the court appl discretion standard. See Howle 792 (3d Cir. 2010), ting Firestone, id. at 111. the standard of s v. Mellon an abuse 625 F.3d 788, This deferential standard applies not only to decisions concerning interpretation of the plan itself, determinations. Trust Funds, but also Luby v. to the administrator's Teamsters Health, Welfare, 944 F.2d 1176, 1187 (3d Cir. 1991). fact-based and Pension In short, "when the arbi trary and capricious standards applies, the decision maker's determination to deny benefits must be upheld unless error or not rational." 1137, 1141 (3d Cir. 1993) was clear 4 F. 3d (internal quotation omitted.) Prior to the Supreme Court's recent decision in Glenn and the Third Circuit Court of Appeals' application thereof in Schwi courts in this Circuit had applied a "sliding scale lf when reviewing claims that the administrator of a plan covered by ERISA had abused its discretion in determining eligibility for benefits. ance Standard Li See Pinto Insurance Co., 214 F.3d 377, 392 (3d Cir. ~~~~~--~~~-------------------------- In reviewing ERISA cases involving denial of benefits by the an administrator, the Third Circuit Court of Appeals uses the phrase "arbitrary and capricious" interchangeably with "abuse of discretion. 1f Howley, 625 F.3d at 793, citing Schwi 562 F.3d at 526 n.2. 13 2000), applying a "heightened arbitrary and capricious standard of review." However, the Supreme Court held in Glenn that when the terms of a plan grant discretionary authority to the administrator, it is appropriate for court to apply a deferential standard of review, even in the ce of a conflict created, for example, when the same enti ty both funds and evaluates benefi t claims. Glenn at are 117, law stating lness by that taking in ERISA cases, account of courts several dif 554 U. S. 105 to rent, "determine 0 en case specific, factors, reading a result by weighing all together;" see also v. First Reliance Std. fe Ins. Co. _ _ _ _ _ _L - _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ 602 (S.D. N.Y. 2008) 'factor' 581 F. Supp. 2d 594, (the existence of such conflicts is "just one among many that may serve as a considerations are in equipoise. 1/) 'tiebreaker' when other The Third Circuit Court of Appeals thereafter acknowledged that its "sliding scale" approach is no longer valid. Instead, courts reviewing the de sions of ERISA an administrators. .in civil enforcement actions brought pursuant to 29 U.S.C. § 1132(a) (1) (B) should apply a de rential abuse of discretion standard of review across the board and consider any conflict of interest as one of seve factors in considering whether t administrator . abused its discretion. Schwi 562 F.3d at 525. An administrator abuses its discretion only if the decision is "without reason, unsupported by substantial evidence or erroneous as a matter of law." Howley, 625 F.3d at 792, quot 14 g Abnathya v. Hoffmann-LaRoche, Inc., 2 F. 3d 40, 45 (3d Cir. 1993). In determining if an administrator's interpretation of a plan is "reasonable,u the Court is directed to consider the llowing factors: (1) whether the interpretation is consistent with the goals of the Plan; (2) whether it renders any language in the an meaningless or internally inconsistent; (3) whether it conflicts with the substantive or procedural requirements of the ERISA statute; (4) whether the [relevant ent ies have] interpreted provision at issue consistently; and (5) whether the interpretation is contrary to the clear language of the an. Howle 625 F.3d at 793. Both during the initial period in which the claimant seeks bene ts and in the summary judgment process, it is the claimant's burden to show she was disabled and entitled to benefits, not the administrator's burden to show she was not disabled. Houser v. Alcoa, Inc., CA No. 10-160, 2010 U.S. Dist. LEXIS 128281, *23 (W.D. Pa. Dec. 6, 2010); Morales-Alejandro v. Medical Card Sys., 486 F.3d 693, 700 whether (lst the Cir. 2007). denial of Similarly, when a court is determining bene ts by the plan administrator was arbitrary and capricious, the burden is on the claimant/plaintiff. Moskalski v. Bayer Corp., CA No. 06-568,2008 U.S. *12-*13 (W.D. Pa. May 16, 2008), Corp., 957 F. Supp. 673, 691 ting Stout v. Bethlehem Steel (E. D. Pa. 1997). 15 st. LEXIS 39970, C. Terms and Conditions of the Policy We begin with a summary of the relevant definitions set out in the Policy and the crite a which must be satisfied in order for a participant to receive short-term disability benefits. According to the version of the short-term disabili ty insurance policy which was in effect between November 2007 when Ms. Brown first applied for STD benefits and June 2008 when she received a letter from First Reliance informing her that she had exhausted all her administrative appeals, 6 all "active, full-time" union employees of National at the Scottsdale facility were eligible to participate in the plan at no cost to themselves. "Full-time" was defined as working a minimum of 40 hours during the person's regular work week. (Supplemental Administrative Record, Doc. No. 30, Exh. A, "Policy," 1.0 and 2.0.) An employee who met the eligibility requirements of the Policy and was enrolled Insured." r STD insurance coverage was referred to as "an "'Actively at work' and 'active work' means the person [is] actually performing on a full time basis each and every duty pertaining to his/her job in the place where and the manner in which the job is normally performed. This includes approved time off such The Policy which was provided as part of the administrative record submitted by Defendant at Doc. No. 21 (see AR 1-19) was not the version in effect during the period noted above. The court directed Defendant to provide a copy of the correct version of the Policy which was filed at Doc. No. 30, Exh. A. 16 6 as vacation, jury duty and funeral leave, but does not include t off as a result of Injury or Sickness. u four conditions under which STD (Policy, 2.0.) insurance coverage There were would terminated; the only one relevant to this matter is that cove terminates on "(2) the date the Insured ceases to be in a class eligible for this insurance. u With some exc 6.0.) ions not relevant here, the Plan paid a maximum , s salary per week of 60% of the Ins "if an Insured: (Policy, a iod of up to 20 wee (1) is disabled due to Sickness or Injury; and (2) becomes disabled while insured by this Policy.u 7.0. ) "Disabled U was defined to mean "t to do the material (Policy, 1.0 and Insured is: (1) unable ies of his/her job; and (2) not doing any work for payment; and (3) under the regular care of a physician." 2.0. ) (Id. , "Injury" was defined as "bodily injury resulting directly from an accident independent of all other causes," and "Sickness" as an "illness or disease causing disability" and explicitly included "pregnancy, complications childbirth, miscarriage from." In the or case abortion, of either or any Inj ury or Sickness, the cause of the disability had to have begun while the person was an Insured. Finally, (Id., 2.0-2.1.) it is important to note that t icy expressly granted discretionary authority to First Reliance, that is: First Reliance Standard Life Insurance Company shall serve 17 as the claims review fiduciary with respect to the insurance policy and the Plan. The claims review fiduciary has the discretiona authority to interpret the Plan and the insurance policy and to determine eligibility for benefits. Decisions by the claims review fiduciary shall be complete, final and binding on all parties. (Policy, D. 5.0.) The November 2007 Application, Denial and Appeal 1. question that Disabili ty beginning November 12, 2007: There is no Ms. on Brown ceased working at National Friday, November 9, 2007, and applied for STD benefits beginning on Monday, November 12, 2007. The question is, was she "Disabled" - as that term is defined by the Policy - as of November 12, 2007? in the previous section, disability bene As noted ts under the Policy may only be awarded if, as the result of Sickness or Injury, Ms. Brown was unable perform the material duties of her job, was not doing other work for payment, and was under the regular care of a physician. second and third crite The a are not in question here, nor is there any claim of disability due to an Injury. Therefore, we need not consider those possible elements of her claim. Was Ms. Brown unable to perform the material duties of her job as the result of a "Sickness" on November 12, 2007? be no. The answer must The condition for which she was being intensively treated beginning on November 12, 2007, was infertility. Al though she argues that undergoing the preliminary procedures in anticipation 18 of the actual IVF surgeries on November 23 and 26 were "complications" of pregnancy, the common definition of a "medical complication" is "an additional disorder or condition that develops during the course an sting oneil or "a secondary disease, an accident or a negative reaction occurring during the course of an illness and usually aggravating the illness." of the Oxford English See, respect Dictionary at ly, the on-line versions www.oed.com/view/Entry/ 37711?redirectedFrom=complication#, definition d, and the American Heritage at Dictionary tp://education.yahoo.com/reference/ dictionary/entry/complication (emphasis added in each case);7 see also Burnham v. Guardian Cir. 1989) fe Ins. Co. of Am., 873 F.2d 486,489 (1 st ("[S]traightforward insurance policy should be given language in an ERISA-regulated s natural meaning.") Logically, treatment for infertility cannot be considered a complication of pregnancy since infertility and pregnancy are mutually exclusive states of being. was not disab Prior to November 12, 2007, it is c ar Ms. Brown d by her infertility since she had, apparently, worked steadily at National beginning in 2004, despite having undergone a tubal ligation in 1993 and an unsuccessful attempt at reversal in 1997. (AR 92.) 7 These definitions do provided to assist the use evidence outside understand the medical not appear in the administrative record but are reader. See Kosiba, 384 F.3d at 69 (A court may the administrative record in order to better issues involved.) 19 Ms. Brown also argues that only reason she was able to successfully conceive through IVF was that she rigorously followed her physician's instructions and remained off work beginning on November 12, 2007. ef at 21.) (Pl£.' s The medical evidence shows that prior to that date, she had undergone a number of tests and examinations to determine November 12, s r fitness for the IVF procedure. began a course of self injections scribed by her physician, which she continued until at least December 7, 2007. 41). During t On (AR period November 12 through November 26, she also cal appointments and examinations at the Magee had numerous Clinic in preparation for the IVF egg extraction and implantation procedures performed on November 23 and 26. However, nothing in the medical evidence provided by Dr. Wakim indicates that he suggested or required that she completely stop working as of November 12, 2007, except the conclusory statement in the attending physician's portion of the application form that s 12 and December procedure. 14, 2007, would be disabled between November depending on the outcome of the IVF (AR 183.) As callous as it may seem, while Ms. desired another Brown may have greatly Id and was willing to undergo significant effort, discomfort, and expense in order to achieve this goal, the question was not whether these treatments required considerable time off from work beginning on November 12, 2007, it is whether s 20 was "Disabled, /I as that term is defined in the Plan. There is nothing to indicate that she was experiencing "Sickness u which resulted in disability as of that date. administrat Thus, we must conclude, based on our review of the record, that the plan administrator's decision denying benefits because Ms. Brown was not disabled as of November 12, 2007, was reasonable and neither arbitrary nor capricious. 2. Notification of denial: The conclusion that First Reliance was not arbitrary and capricious in denying disability benefits while Ms. Brown was undergoing the in vitro fertilization process does not end our analysis, however, because Plaintiff also claims the denial letter ERISA requirements. January 18, 2008, did not conform with Specifically, Ms. Brown argues that the letter iled to include a description the additional information needed to perfect her claim and why it was necessary. Moreover, it failed to mention a reason for the denial which would be given in the letter of June 12,2008 (discussed below), that is, she was not considered an employee as of November 12, 2007. ERISA requires that every (Plf.'s Brief at 10-11.)8 employee benefit adequate notice in writing to any participant. plan "provide .whose claim for benefits under the plan has been denied, setting forth the specific reasons for such denial, written in a manner calculated to be Because Plaintiff's brief frequently combines arguments concerning both denial letters, in order to avoid addressing those arguments twice, we have chosen to address them in the section below discussing the June 12, 2008 letter. 21 understood by the participant." 29 U.S.C. § 1133(1). The associated regulations require that the notification of any adverse benefit determination shall set forth, in a manner calculated to be understood by the claimant (i) The specific reason or reasons for the adverse determination; (ii) Reference to the speci which the determination is based; c plan provisions on (iii) A description of any additional mate al or information necessary for the claimant to perfect the claim and an explanation of why such material or information is necessary; (iv) A description of the plan's ew procedures and the time limits applicable to such procedures, including a statement of the claimant's right to bring a civil action under section 502(a) of the Act following an adverse benefit determination on review[.] 29 C.F.R. § 2560.503-1(g) (i}-(iv). Under these regulations, a notice is sufficient if it is "in substantial compliance with the governing regulation." v. Hartford Li & Accident Co., --------------------------------- See Mazur CA No. 06-1045, 2007 U.S. Oist. LEXIS 99927, * 37 (W.O. Pa. Nov. 8, 2007); Kao v. Aetna Life Ins. Co., 647 F. Supp.2d 397, 411 (D. N.J. 2009). satisfies these requirements, When determining if the notice court must consider all exchanges between the claimant and the plan administrator in order to determine if the information was adequate under the circumstances. 22 Wade v. Hewlett-Packard Dev. Co. LP Short Term Disability Plan, 493 F. 3d 533, 539 (5 th Cir. 2007); Houser, 2010 U.S. Dist. LEXIS 128281 at *29. We begin our consideration of Plaintiff's "inadequate notice" argument with a summary of the relevant information provided by Ms. Brown, her employer, and Dr. Wakim in support of the initial claim. Ms. Brown stat 12, 2007. that she was first unable to work as of November The form described Ms. Brown as a member of insurance Class 5 under the First Reliance Policy and further indicated that she was not as of that date rece ng sick leave benefits from the employer or unemployment compensation. The stated reason for stopping work was "in vitro Attached to the form was a statement rtilization." dated November 21, 2007, and signed by her attending physician, Dr. Wakim. In that portion of the form, diagnosis was "2° infertil y; 1/ Dr. Wakim i cated that the she required weekly/daily treatment; and the condition was not due to injury or sickness arising from her employment. The doctor further stated that Ms. Brown was not able to perform her job continuously from November 12 through December 14, 2007, but the date she would be Ie to return to work would depend on the results of a pregnancy test following IVF. (AR 184.) The cover form was signed by Susan Ahlborn on behalf of National on November 28, 2007, and, according to the imprinted fax Defendant received both documents the same day. 23 (AR 183.) record, According to the administrative record, on December 3, 2007, Ellen Ghirlanda, an employee in the STD Claims Department of rst Reliance, called Ms. Brown and explained the policy definitions of illness and injury. When Ms. Brown confirmed that the treatments she was undergoing were elective, Ms. Ghirlanda noted that "I told [her J policy does not cover elective procedures and we need [medical records] for our medical staff to review. disability covers illness & injuries." Again I explained that (AR 40-41.) Ms. Ghirlanda was corrected later that day by Rosetta Davis, a Claims Examiner, who pointed out that "elective medical procedure and surgery are not exclude[d] by the STD policy. However, we must determine if the claimant is truly disabled a er undergoing an electi ve medical procedure or elective surgery. aimant's medical records and refer I would request the r medical review to determine is she disabled and the duration of the disability." Ms. explai Ghirlanda telephoned Ms. Brown t (AR 40.) following day and that the medical department needed to review the complete file and informed her twice that the "policy does not exclude elective procedures, but I need guidance weather [sic] this is considered an 'illness' according to the contract. I will contact her when review (AR 41.) is complete." In a medical review performed the next day, December 5, 2007, Laurie Frate, a registered nurse, 24 commented, "Per the attending physician statement the She is undergoing in aimant's primary diagnosis is tro fertilization. This is not cons an illness and does not support work impairment." On December 7, telephone. Ms. Brown and Ms. Ms. Brown i il y. red (AR 34.) Ghirlanda spoke her that the inj ections to in by litate production of ova had begun on November 12 and that she was still self-injecting other medications. Brown] that based on the and not a disability. Ms. Ghirlanda "explained to [Ms. cal [sic] we have this is not an il However, we are going to request medical records from Dr. Wokim [sic] from 11/12/07 to present. [sic] supports all the s review the claim again ef ss If medical cts she has mentioned then we can disabil y. /I In another calIon r 11, Ms. Ghirlanda told Ms. Brown that despite a request to Dr. Wakim, First Reliance had not the medical records. Ms. Ghirlanda that she was pregnant. Ms. Frate reviewed the Ms. Brown told (AR 41.) Ie again and noted on December 20, 2007, that "Per review of the medical records submitted the cIa undergoing medications r preparation for in vitro fertilizat The claimant underwent embryo transplant on 11/26/07. records does not indicate As noted in prior RN was ew of adverse reaction to the medicat a diagnosis of infertility or preparation for implantation does not preclude work capacity." 25 (AR 34.) On January 7, Ms. Ghirlanda explained in another call to Plaintiff that there was no evidence in the medical records about complaints of side effects. When Plaintiff said "they" were not sending the correct information and that it would "take forever" to get documentation from her physicians, Ms. Ghirlanda told her, "we will be sending a denial letter based on the in received. rmation we have She can appeal the denial and forward additional medical [records] w h the appeal." (AR 41-42.) On January 18, 2008, Ms. Ghirlanda wrote to Ms. Brown, stating that the insurer had received her claim "which indicated you were out of work and disabled due to In Vitro Fertilization, secondary to pregnancy." National's the mate She pointed out that Defendant's policy with fined "Disabled" to mean "the Insured is unable to do al duties of her job," and defined "Sickness" as meaning "illness or disease causing disability which begins while an Insured. Sickness ludes pregnancy, childbirth, miscarriage or abortion, or any complications there from." She then stated, "The In Vitro fertilization procedure is not considered an illness according to your employer's policy." Moreover, the medical record did not reflect any of the side effects from the "treatment" refe (presumably ng to the IVF procedure) which would have prevented her from working. The request for disabili ty benefi ts beginning November 12, 2007, was therefore denied. (AR 154.) 26 The letter continued with what appears to be standard language outlining how Ms. Brown could request a review of the ision, time frame in which she could expect a response, and the materials she was entitled to receive upon request, e.g., a copy of her claim file, the internal guidel and rules First Reliance used in reaching its decision, and other information relevant to her claim. It also advised her about her rights under ERISA. the scussion 3. January (AR 155.) 18, letter: 2008 Returning to the criteria set out in ERISA regulations as to the content of a letter denying a claim for benefits, we conclude the January 18, reasons 2008 letter properly included the r the adverse det na t ion, i . e. , cific reason or "the in vitro fertilization process is not considered an illness according to your employer's policy"9 and "the medical documents received list no complications of s to effects from your treatment." definitions of Disabl provisions on which the It referred and Sickness, i. e., the specific plan ermination was based. It stated that Ms. Infertility is a medical condition which has been recognized in the case law as a disorder of the reproductive system. See, e.g., Erickson v. Ed. of Governors of State Colls ... No. 95-2541, 1997 U.S. Dist. LEXIS 13313, *12-*13 (N.D. IlL, Sept. ,1997). It is possible that the Policy could have icitly identified infertility as an illness and therefore unde ng treatment for it might have been covered by the short-term disability Plan. See, e.g., Egert v. Conn. Gen. Life Ins. Co., 900 F.2d 1032, 1037 (7 th Cir 1990), in which the court found that it was arbitrary and capricious for the administrator of a medical insurance plan to exclude treatment of infertility because the plan specifically identified the condition as an illness in its own internal guidelines. 27 9 Brown could request in writing a review of this decision and should provide with her request "any written comments, records or other information rtaining to your claim for benefits." portion of denial letter could have been more explici t, Ms. Brown While this had already been advised by telephone at least as early as January 7, 2008, that if she also claimed that side effects from the medications administered between November 12 and December 7, 2007, were disabling, First Reliance would need "documentation from her physi side effects." (AR 41.) an that shows she complained The letter also included the necessary statement of Ms. Brown's rights under ERISA. letter We conclude, substantially therefore, complied that the January 18, 2008, with ERISA requirements See Miller v. communicating an adverse decision. Am. Airlines Inc., No. 10 1784, 2011 U.S. App. LEXIS 1462, *30-*36 (3d Cir. Jan. 25, 2011) (comparing cases and concluding that the letter sent to Miller was legally deficient in part because it did not mention the aimant's speci c diagnoses or the precise in rmation that was lacking and did not provide any instructions how Miller could achieve a favorable determination); Houser, 2010 U.S. Dist. LEXIS 128281 at * 30 (letter was adequate where it quoted specific plan provisions on which denial was based, informed plaintiff s additional medical or vocational appeal rights); 28 in rmation, could submit and explained her CA No. 08-5416, 2010 U.S. Dist. LEXIS 98646, * 26 (D. N.J. Sept. 21, 2010) (there was "nothing cryptic" about a denial letter which sta t "the medical evidence on file does not support [Plaintiff's] inabili ty to perform, on a full time basis, the material and substantial duties of any occupation for which he is qualified" and explained that he could "submit additional information or comments he deems pertinent for review.") Fourth Circu stated in As the Court of Appeals for the lis v. Met litan Life Ins. Co. Ellis has somehow. .come to the erroneous belief that fe is under an obligation to inform her of what she needs to tell MetLife in order to obtain disability benefits. That is not MetLife' s role as a fiduciary. MetLife must treat each claimant with procedural fairness, but, because it must also guard against improper claims, it is not its duty to af rmati vely aid claimants in proving their claims. MetLife' s denial letter. substantially complies with the applicable ERISA regulations in all material re s. 126 F.3d 228, 235 4 ¢ (4 th Cir. 1997). 1 of the November 2007 application: As noted above, Ms. Brown did not appeal this decision until May 16, 2008, after had filed her second STD claim on May 6, 2008, which is discussed in the following section. Ghirlanda on May 9, 2008, During a conversation with Ms. Ms. Brown stated she did not appeal the prior decision because she did not know s could. Ms. Ghirlanda explained the appeal procedure (which had already been explained in the January 18, 2008 letter) and specifically noted that "she should 29 send in as much additional medical docs. her im. " Ms. [as possib ] to support (AR 42.) Brown appea the January 18 decision on May 16, stating that Defendant had indicated in s denial 2008, er (1) "IVF isn't considered a sickness" and (2) benefits were denied in part because the medical evidence did not reflect that she had disabling side ef s from the medications she was taking as part of the IVF preparation process. side ef She (AR 85.) rted that she had mentioned cts to her nurse and enclosed with her letter copies of her pharmacist's drug monographs on which she had highlighted those side ef s she experienced. She concluded by reminding First Reliance that she was willing to return to work in December but National was unable to accommodate her restriction to light work. Unfortunately, this appeal letter information which would have not enclose helped Ms. type of Brown's namely, cause, medical evidence from Dr. Wakim regarding the purportedly disabling side ef disab on cts or any anation of why he conside November 12 through December 18. numerous telephone occasions Reliance did not consi r the and submitted conclusion was a statement in writing incorrect or Dr. Wakim confirming 30 that rtilization in vitro from Brown Ms. Brown had been told Sickness which could give rise to disability. and Ms. First ss a Had Plaintiff sought explaining that she had, why that in ct, experienced debilitating side effects from the medications, it is possible Defendant would have reconsidered its initial decision. On May 27, 2008, after rst Reliance received Ms. Brown's appeal, a letter was sent to her, enclosing an authorization allowing the Quality Review Unit to obtain updated medical information if it was needed during the review process. (AR 83-84. ) There is nothing in the record indicating that Ms. Brown completed and returned the authorization. On May 29, 2008, Laura M. Quinn, a Senior Benefit Analyst in Defendant's Quality Review Unit, discuss her appeal. 42-43.) called Ms. Brown to Ms. Quinn explained that when she reviewed the additional materials Ms. Brown provided wi th her appeal letter, she had decided that an independent fertility spec should review the file Ms. Brown "express fore Ms. Quinn issued her assessment. list When frustration" at this step, Ms. Quinn said she would try to expedite the independent physician review in order to get a decision as quickly as possible and would call her wi th a status update. In answer to Ms. Brown's questions about STD coverage for matern y leave after her child was born, Ms. Quinn stated, "I advised that her current pregnancy is of loss] i rectly related to her IVF at the [ I cannot answer her question at this time as it will depend on whether her impairment is supported at the time of her work stoppage." Ms. Brown sta that she understood. 31 (AR 82.) As promis , Ms. Quinn promptly sent the file compiled through May 29, 2008, to Medical Evaluation Specialists and asked for the ew be compl informed Ms. as soon as possible. (AR 43.) On June 9, she Brown that she had received Dr. Abbasi's report and advised Ms. Brown by telephone on June 12, 2008, own review and Dr. decision by the C Abbasi's report, t based on her she had dec the initial ims Department denying benefits had been correct. According to Ms. Quinn's notes, Ms. Brown terminated the call before had an opportunity "to discuss the facts and Policy provisions relevant to reaching [her] decision." (AR 44.) Ms. Quinn followed up with a letter the same day. E. The May 2008 Application and Denial 1. May 6,2008 applica on: Meanwhile, Ms. Brown had submitted a second application for STD benefits on approximately May 6, 2008, stating that she was unable to work because of her pregnancy as of November 9, 2007. (AR 152 - 15 3 . ) She further indicated that she was still off work, but should be able to return on September 29,2008. Nolfi, The attending physician's statement, signed by Dr. James indicated that she first consulted with him regarding her pregnancy on January 31, 2008, and that she was unable to perform her job inasmuch as she could not Ii unable to stand continuously. the dates when more than 10 pounds and was However, the form failed to provide was unable to work. 32 Similarly, the part of the rm to be completed by her employer was incomplete except for National's name, address, and telephone numbers. Ms. Ghirlanda called to discuss the second claim wi th Ms. Brown on May 9, 2008. provide dates 10 She informed Plaintiff that r doctor did not for her disability and that employer section was incomplete and unsigned. Ms. Brown told Ms. Ghirlanda that she had been disabled since November 2007 and that when s a er her IVF procedure, National could tried to return not accommodate limitations. She asked Ms. Ghirlanda to return t her forms to her. 1l On May 15, Ms. Ghirlanda spoke with Susan Ahlborn who had signed the first claim form on behalf of National. Ms. Ahlborn confirmed that Ms. Brown had been released by her doctor for light duty on December 18, 2007, but that when National could not such work, Ms. Brown was laid off the same day and was recei compensation. 12 2. ng unemployment (AR 42.) The June 12, 2008 denial letter: Between May 15 and June 12, Ms. Quinn and Ms. Brown spoke several more t s on the 10 This was the same call discussed in the previous section in which Ms. Brown and Ms. Ghirlanda discussed the process by which Plaintiff should the initial denial. 11 The Court has been unable to determine from the administrat record if the second set of claim forms or copies thereof were actually returned to Ms. Brown. They appear at AR 152-153 and no other revised or amended versions are in the record. This statement is in direct contradiction to Ms. Brown's representation in the benefits application that she was not receiving unemployment compensation benefits as of May 6, 2008. (AR 152.) 33 telephone, as summarized in the previous section. call r on June 12, 2008, in which Ms. Quinn informed Ms. Brown that she was affirming the initial Ms. Brown. sion denying benefits, Ms. Quinn wrote to (AR 57-61.) In that the appeals process had employee (Ms. Quinn) ter, Ms. Quinn pointed out that lved decision making by a First Reliance independent of the person who had made initial decision (Ms. Ghirl ), and that Dr. Wakim's file from June 2006 through April 24, 2008, along with records from Dr. Nol been reviewed by Dr. Abbasi, a board certified spe , had alist in obstetrics and gynecology who was also certified in reproduct endocrinology and infertil Dr. Abbasi's findings, y. The internal review, incorporating to the conclusion that the had 1 cal evidence did "not substantiate any complications following your in vitro fertilization or re pregnancy that would have precluded you from performing the mate al duties of your job at the t your work stoppage (11/12/07).n Referring to the p letter that "in vitro consti tute a 'Sickness,' a Ms. Quinn explained that of (AR 57.) ous statement in the January 18, 2008 rtili zation, in and of itself, does not ng to the terms of the group Policy t i l purpose of the review "was to in the medical data documents the presence of a physical or mental heal th condition that wou (AR 58. ) limi t your ability to perform your job. II Not only did the two surgical procedures occur on November 34 23 and 26, 2007, well a medical reports associated with er Ms. Brown had stopped working, but the indicated either that process. there were The no complications review had included consideration of a Medical Certification Statement for Employee's Own Illness (AR 102), but this document was given I tIe weight inasmuch as it was not signed or dated by any medical provider. restrictions indica in that document, i.e., no Ii The ing greater than 10 pounds and no continuous standing, were again noted in a return-to-work form December 18, 2007 (AR 103), about which First Reliance stated, "in our review of the medical data, we must concl that the level of the severity of your condition is unsubstantiated by the documentation from your treatment providers, /I largely because there were no complaints in the medical record relat to either the IVF process or the pregnancy itself. This position was corroborated by Dr. Abbasi, who had stated he had reviewed "the documentation and determined that no restrictions and limitations are supported by the records./I (AR 58-59.) Ms. Quinn also referred to the documentation provided about the effects of the drugs Ms. Brown had taken during the potential s weeks I stat ng up to and immediately after the IVF process. that these materials, "of a gene that you actually expe records did not c nature, do not support enced the side effects, I ude any references 35 She to /I because the medical them; moreover, the specific conditions Ms. Brown had identified were symptoms which "typically do not preclude work function." Based on this review of all the mater (AR 59.) Is Ms. Brown had submitted and as confirmed by Dr. Abbasi's independent assessment, Ms. Quinn concluded that Ms. Brown had been capable of performing the material duties of r job as of November 12, 2007, that is, she was not "Disabled" as that term was defined by the Policy. Moving on a discussion of t Reliance determined that Ms. May 6, 2008 application, First Brown's coverage under the National Policy had terminated effective November 12, 2007, and that any claim for disability beginning after that date would not covered because she had "never rejoined an 'Eligible Class' of employees." (AR 59. ) Based on the definition of "Eligible Classes" in the Schedu of Benefits Provision of the Policy, the definition of "full-time" in the Definitions section thereof, and the evidence in the cIa file that she never returned to work at National, Ms. Brown was not covered by the Policy after November 12, application, see 2007. Consequently, the second ng STD benefits beginning on November 12, 2007, and based on her pregnancy, had been denied. Ms. Quinn noted that the claim decision was now final and that Ms. Brown had exhausted any administrative remedies available under the Policy. The closed with a summary of Ms. Brown's (AR 60-61. ) 36 ghts under ERISA. ter After Ms. Brown engaged counsel to file suit, r attorney attempted to argue that Plaintiff had been denied the opportunity to appeal the decision denying the claim she submitted on May 6, 2008. Richard D. Walsh, Director of the First Reliance Quali ty Review Uni t, wrote to Plaintiff's counsel on November 6, 2008, explaining that in Defendant's the first inion, the two claims were not separate even though indicated that she was sabled due to the in vitro rtilization and ultimate pregnancy while the second cove a claim disability due to pregnancy. Because Ms. only Brown had stated in both applications that her disability began November 2007, and because she never returned to work between the IVF process and the pregnancy/delivery period, First Reliance regarded dis ing conditions to be one event. allegedly He rei tera ted the conclusion that the second reason for denying the May 6, 2008 claim it were considered a separate claim covered by the even if was that Ms. Brown was not rst Reliance STD policy after November 12, 2007. (AR 54-55.) 3. Discussion and con usion: Ms. Brown's second application form was incomplete and internally contradictory. She indicated in the first part of the form that her disability began November 12, 2007, when she was def i tely not pregnant, even though that was the purported cause of her disability. The part completed by Dr. Nolfi indicated that he had not begun treating Ms. Brown until 37 more than two months later, on January 31, 2008, and provided no dates when he considered that was continuously unable to work. The portion to be completed by her employer was blank except for contact information. Ms. Brown was advised by telephone of these problems with the claim form as ea no steps to rectify y as May 9, 2008, yet it appears she took omissions. Since it is clear from the second application that Ms. Brown believed that her disabili ty began at the time she Ie work to begin IVF treatments and would continue through the deli very of her child, it was not unreasonable for rst Reliance to consider both applications simultaneously as two aspects of the same purported disabili ty. by Ms. Quinn on May 29, current pregnancy . . In addi tion, Plaintiff had been informed 2008 that First Reliance considered "her directly related to her IVF" and that coverage during her pregnancy "will depend on whether her impairment supported at time of her work stoppage." Moreover, we wi th Defendant that (AR 82.) Ms. Brown eligible in any case to submit the second application. Policy, cove is was not Under the granted to an Insured terminates when she "ceases to be in a class eligible for this insurance." (Policy, 6.0.) Classes eligible for the insurance are limited to "active, full-time employees." (Id., 1.0.) As pointed out in the June 12,2008 er, Ms. Brown conceded in the second application that she did not return to work for even one day after November 12, 2007. 38 We conclude that denial of the application bene ts submitted in May 2008 was neither arbitrary nor capricious and that First Reliance adequately conveyed the reasons for t denial in the letter of June 12, 2008. Plaintiff's_Remain~ng F. Arguments Ms. Brown raises several re ted arguments in support of her motion for summary judgment which we will address briefly. She first contends that the term "active" is never defined and that the definitions of "actively at work" and "active work" apply only when determining when coverage an employee becomes ef ive (see Policy, 6.0), but these cannot be used generally to define an Eligible Class. Therefore, the Policy is vague and, under princ les of trust law and general contract construction, it should be construed in her favor. f.' s Brief at 14, ci ting Tester v. Reliance Std. fe Ins. ----------------- Co., 228 F.3d 273, 375 (4 th Cir. 2000), and Blue Shie 67 F.3d 53, 57 (4 th Cir. 1995).) We need not address this argument in detail 13 because there is no question that as of November 12, 2007, Ms. Brown was no longer ]3 We agree with Defendant that under Third Circuit precedent, the general principles of contract interpretation and in particular the reasoning of Tester on which Plaintiff relies do not apply when a court is reviewing denial of benefits under a deferential arbitrary and capricious standard, but only when the standard is de novo. While the Third Circui t has applied the contra proferentem principle of contract construction in ERISA cases, it has done so only to decide if a plan granted discretion to the administrator. See Heasley v. Belden & Blake Corp., 2 F.3d 1249, 1257-58 (3d Cir. 1993). In Ceccanecchio v. Cont'l Cas. Co. No. 01-4468, 2002 U.S. App. LEXIS 21496, *19-*20 (3d r. Oct. IS, 2002), the Court mentioned this issue without resolving it, but noted that a number of other courts had 39 working "full-time" which means, Scottsdale J for a National employee at the ility, she would have been working "40 hours during regular work week." Even if one accepts for sake of argument that "actively at work" and "active work" do not equate to "active," Ms. Brown still cannot show that she was a "full-time" employee at any time after November 9, 2007. In fact, the record shows that as of December 18, 2007, she was laid off and receiving unemployment compensation. (AR 42.) Plaintiff next argues that First Reliance or National should have informed her that she would not be eligible for STD benefits unless she worked at least one day a in December 2007. r she was allowed to return However, she cites no case law or ERISA regulation which requires such notification. (Plf.'s Brief at 12-13.) ERISA does place certain fiduciary duties on the plan administrator to inform participants of such things as cancellation of the mat al reductions in coverage, or remedies available to them if e.g., Peralta v. Hi they are denied benefits. lnc., an, 419 F.3d 1104 (a) (1) (B) fiduciary 1064, in (9 th Cir. 1071 support of responsibilities" the 2005), principle encompass ic Business ting 29 U.S.C. that ERISA's obligations on § "broad the plan administrator to timely notify employees of termination of their concluded that the doctrine is inapplicable when invoking the arbitrary and capricious standard of review in considering the plan administrator's interpretation of the terms of a plan. 40 benefits. However, this Court is unaware of any requirement that the employer or plan administrator must provi how suggestions about ts might be reinstated after termination in addition to the formation provided in the Policy or the P Met litan Life affirmat Des supra ("it ly aid claimants is not See Ellis v. [the fiduciary's] proving their c .") duty to The STD Plan ion provided to National employees states that if an employee has been on an approved leave of absence or on a temporary layoff, the insurance may be reinstated "if you return to Active Work with [National] within the pe Bene s page," that Nat I Envelope is, Co od of time as shown on the Schedule of wi thin six months. ion Short Term (Doc. Dis 30, ility Exh. Insurance Program Certificate with Summary Plan Description, 5.0-5.1.) As a in the Plan, Ms. Brown is presumed to be familiar with part and understand her rights and obligations thereunder. v. C, See Burstein Ret. Research Found., 334 F.3d 365, 379 (3d Cir. 2003), citing 29 U.S.C. § 1022(a) and (b), noting that the latter requires the summary plan descri ion to be "accurate" and "sufficiently because it is the document to which employees are most comprehens " lik~ly r to re in obtaining information and making decisions about how they are affect by the terms of the plan. term and reinstatement is p Since "Act Work" is a defined sed upon return to "Active Work," Ms. 41 Brown's argument that First Reliance breached its failing to provi additional information to her is unavailing. Plaintiff next argues that capriciously in regard to rst Reliance act the in communicated) to her concerning rmation denial of benefits. the "deficiencies" identified in t the ERISA provis arbi trarily and communicated Ms. Brown claims that Defendant's refusal to allow notice to the duciary duty by (or not That is, r to remediate June 12, 2008 letter violates n which requires benefi t plans to provide adequate an beneficiaries. In hindsight, the reasons more clear to Ms. (Plf.'s Brief at 13-14.) denying STD benef Brown had s may have been rst Reliance written two separate letters, the first affirming the ision in the January 2008 letter that undergoing IVF was not a sickness giving rise to disability and the second in rming Ms. Brown that the second application would not considered it was incomplete or, alternatively, that she was not in an was not covered. We cannot find, however, that First Reliance acted iciously in considering the two applications arbi trarily or together espe became pregnant and therefore igible Class when ally since Ms. Brown herself stated applications that her disability began November 12, 2007. as noted above, Ms. Quinn advis Ms. both Moreover, Brown of the relationsh between the two applications as early as May 29, 2008. 42 in PIa the iff also contends special standard of t the language of the Plan violates care imposed by ERISA upon a plan administrator to discharge its duties "solely in the interests the participant and beneficiaries" of the Plan. (Plf.'s Brief at citing 29 U.S.C. § 1104 (a) (1).) 14-19, As previously noted, First Reliance was the plan administrator for the National Plan and exercised final and binding discretionary authori ty over Defendant was the with making. early a fiduci U.S.C. § 1002 (21) (A). duties decision respect a ERISA with respect to It was to Under provisions, Plan. See 29 refore required to "discharge [its J plan solely in the rest of the participant and beneficiaries," and to discharge those duties "with the care, skill, prudence, and diligence under the circumstances then prevailing that a prudent man acting in a like capacity and familiar with such matters would use." "But in dis rging these 29 U.S.C. § 1104 (a) (1) (A) and (B). duties, [the administrator required to abide by the plan documents." al so Lockheed No. 10-1212, 2011 U.S. App. LEXIS 2715, Martin *12 (3d Cir. Bicknell v. is] . 10, 2011), ting 29 U.S.C. § 1104 (a) (1) (D). Where the administrator does so, "we cannot conclude that it breached any of its dut s as fiduciary." Bicknell id. Since we conclude that coverage requirements and its both Defendant's interpretation application of the relevant provisions to the facts 43 Ms. Brown's case were consistent with the conclude there has been fined terms in the Policy, we further no breach discharging its duties under t Finally, substantial Ms. Brown evidence of its fiduciary duties in Plan. contends supporting that her First claim Reliance when it ignored refused to acknowledge that she was legitimately limi ted to only light duty work owing to the risks inherent in her IVF treatments and subsequent pregnancy. Specifically, she argues that both attending physicians' reports restricted her to work which precluded continuous standing and lifting more than ten pounds. Certi She also references the Medical cation for Employee's Own Illness which indicates in the same handwriting as that in Dr. Wakim's report that she was subject to the same restrictions. But, she argues, First Reliance "paid no attention" to these documents in concluding that "the level of the severity of [her] condition is unsubstantiated by the documentation This failure to acknowledge her from [her] treatment providers." limitations was an abuse of discretion, compounded by Defendant's reliance on restrictions records. II Dr. and Abbasi's unsubstantiated limitations are conclusion supported according that "no to the While recognizing that ERISA plan administrators are not required to afford any cial deference to the opinions of a treating physician, she contends that they may not arbitrarily refuse to credit a aimant's reli le evidence, 44 including those opinions. Because there is no evidence to contradict r physicians' limitations to no work during the period she was undergoing IVF treatments and light duty after she was released to return to work on December 18, 2007, rst Reliance clearly acted arbitrarily and capriciously in denying benefits. (Plf.'s Brief at 19-23.) In order to address this argument, it is necessary first to consider precisely what each physician stated in his records. Dr. Wakim did state that Plaintiff was continuously unable to work from November 12 through December 14, discussed above, there is not this assertion. 2007. (AR 184.) However, as ng in his medical notes to support By way of example, there is no reference to any conversation wi th Ms. Brown suggesting that being completely off work during that month was a requirement for undergoing the IVF procedure. Similarly, although Plaintiff was advised by telephone on May 9, 2008, that Dr. Nolfi's May 6, 2008 report was unacceptable, in part because it failed to identify the dates on which she was continuously unable to work, there is no evidence in the record that Plaintiff attempted to recti this omission. To adopt Ms. Brown's position that these opinions should be controlling even though there is no support for them in the medical record would mean that any time a claimant's physician made such a statement, it must necessarily be accepted by the plan administrator. Plan v. Nord, 538 u.S. 822, 831 (2003) 45 See Black & Decker (ERISA does not impose a duty on plan administrators to accord special deference to the opinions of treating explanation physicians, on nor is administrators there when a heightened they reject burden a of treating physician's opinion.) At the same time, we agree with Plaintiff that a plan administrator may not "arbitrarily refuse to credit a claimant's reliable evidence, including the opinions of a treating physician." Stratton v. E.I. DuPont de Nemours & Co., 363 F.3d 250, 257-258 (3d Cir. 2004), quoting Black & Decker, id. at 834. However, the administrative record shows that far from arbitrarily refusing to credit the opinions of Drs. Wakim and Nolfi, First Reliance not only reconsidered their medical records from June 2007 through at least April 2008, but also provided those records to Dr. Abbasi who arrived at the same conclusion - Plaintiff was not disabled at the time she left National to undergo in vitro fertilization. As the Court of Appeals stated in Stratton, "[aJ professional disagreement does not amount to an arbitrary refusal to credit." Id. at 258; see also Schlegel v. Life Ins. Co. of N. Am., 269 F. Supp.2d 612,627-628 (E.D. Pa. 2003) (reliance on recommendations of non-treating physicians over those of treating physicians does not necessarily mean that denial of disability benefits was arbitrary and capricious.) Having considered each of Plaintiff's arguments for summary judgment in her favor, we find them unavailing. 46 We also conclude that the review process d not reveal procedural irregularities that might give us reason to doubt Defendant's "fiduciary neutrality." Post, 501 F.3d at 165. Where, as here, the Plan vests the administrator with discretion to determine eligibility for benefits, this Court is not free to substitute its own judgment for that of the plan administrator. ting Lasser Cir. 2003). v~ Houser, 2010 U.S. Dist. LEXIS 128281 at *22, Reliance Std. Life Ins. Co., 344 F.3d 381, 384 (3d Inasmuch as Plaintiff has the burden at this stage of showing that First Reliance abused its discretion by denying her disability benefits, we therefore grant summary judgment in favor of Defendant. March 17, An appropriate Order follows. 2010 William L. Standish United States District Judge 47
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