Employee Benefits

Dist. Ct did not err in granting defendants-plan administrator’s and insurance company’s motion for summary judgment in ERISA action alleging that defendants wrongfully denied plaintiff’s application for long-term disability benefits pursuant to terms of employer’s disability plan even though plaintiff claimed that her back condition limited her ability to work for only four hours per day. Defendants’ denial was not arbitrary or capricious where decision was based on opinions of three doctors who believed that plaintiff could perform full-time sedentary work, and plan administrator could delegate decision to third-party even though right to delegate was not contained in plan. Fact that plaintiff’s doctor rendered contrary opinion did not require different result. Ct. also rejected plaintiff’s contention that defendants failed to provide her with sufficient basis for its denial so as to give her adequate notice of need to generate new medical evidence to support her internal appeal of denial.

Dist. Ct. did not err in affirming final decision of Social Security Commissioner that denied claimant's application for SSDI benefits based on his diagnosis of "brittle bone disease." Claimant's medical records did not substantiate his testimony regarding his limitations during relevant time, and ALJ could rely on vocational expert's testimony indicating existence of sedentary jobs that were available to someone with claimant's condition.

Dist. Ct. did not err in granting defendants-health plan and its administrator’s motion for summary judgment in ERISA action alleging that defendants wrongfully denied certain medical bills incurred during plaintiff’s treatment for cancer where plaintiff used physicians and hospital that were not in plan’s network of medical providers, and that defendants breached fiduciary duty by failing to alert plaintiff to fact that physician and hospital were not in defendant’s network before plaintiff had incurred said expenses. While plaintiff argued that plan’s denial was unreasonable where record was unclear as to actual plan that covered plaintiff’s medical expenses, Ct. found that defendant could deny instant claim where plaintiff was aware of precise plan to which she had enrolled, and where plaintiff conceded that doctors/hospital involved in cancer treatment were not within said network. Moreover, defendants did not breach any fiduciary duty, even though plaintiff made two telephone calls to plan on day of her admission into hospital to undergo cancer treatment since: (1) plaintiff did not timely alert defendant in either phone call that she had question as to whether said treatment would be covered under plan; and (2) plaintiff failed to follow instructions in plan to determine whether doctors or hospital were within applicable network. Remand, though, was required for re-determination of statutory damages arising out of defendants’ failure to timely provide copy of plan documents where Dist. Ct. failed to consider all of plaintiff’s arguments in support of such award. (Partial dissent filed.)

Record failed to contain sufficient evidence to support ALJ's denial of claimant's request for Social Security disability benefits based on claim that claimant suffered from various ailments including chronic obstructive pulmonary disease, osteoarthritis, obesity, vascular dementia, depression, panic disorder and anxiety. ALJ must evaluate all relevant evidence when determining claimant's residual functional capacity (RFC), and thus remand was required where ALJ failed to incorporate into discussion of claimant's RFC claimant's mental impairments and certain physical impairments. Ct. similarly noted that ALJ had failed to formulate RFC that was sufficiently specific as to how often claimant must be able to sit and stand.

Record failed to support ALJ's denial of claimant's application for Social Security disability benefits arising out of claimant's nerve disorder that impaired his vision and caused him to have severe headaches, where ALJ found that claimant was not credible with respect to nature and severity of his symptoms. Record contained evidence to support claimant's contention that he suffered from severe headaches, and fact that claimant had gaps in treatment for his condition did not support finding that claimant was not credible where ALJ failed to ask claimant to explain reasons for said gaps in treatment. ALJ also failed to adequately develop full and fair record to determine why non-treating medical expert was skeptical about severity of claimant's headaches.

Dist. Ct. did not err in dismissing for failure to state cause of action plaintiffs-plan beneficiaries' putative class action under ERISA alleging that defendants-plans wrongfully deducted from disability benefits issued under instant plans Social Security disability benefits under 42 USC section 423 received by plaintiff on their own behalf, as well as amounts payable on behalf of plaintiffs' children under 42 USC section 402(d). While plaintiffs argued that reduction due to receipt of children's benefits was improper since said benefits were not "loss of time disability" benefits as that term was contemplated in plans, Ct. of Appeals found that instant deduction was appropriate since: (1) Social Security disability benefits, whether primary of dependent, are "loss of time disability benefits" because they are based on plaintiffs' disabilities; and (2) offset provision in instant plans referred specifically to Social Security disability benefits paid to children.

Dist. Ct. did not err in granting plaintiff-pension fund’s motion for summary judgment in ERISA action against defendant-employer seeking defendant’s contribution to pension fund required under 2005 collective bargaining agreement, as well as Participation and Trust Agreements that called for defendant to make said payments throughout life of 2005 collective bargaining agreement, even though defendant and union entered into 2008 collective bargaining agreement 6 weeks prior to expiration of 2005 collective bargaining agreement that called for immediate stoppage of said payments. Terms of Participation and Trust Agreements expressly and clearly required defendant to make pension contributions throughout stated term of 2005 collective bargaining agreement and prohibited defendant from making subsequent agreement to stop making said payments during said term. Dist. Ct. also did not err in denying defendant’s request to expand discovery,even though defendant asserted that such discovery was necessary to identify evidence of latent ambiguities in terms of subject documents.