Employee Benefits

Dist. Ct. erred in granting defendant-plan administrator's motion for summary judgment in ERISA action, where record contained sufficient facts to support allegations that defendant breached its fiduciary duty to plaintiff-HMO member by providing her with summary of benefits that was less than clear as to whether her surgery was covered under plan by inviting her to call its customer service representative with questions about coverage but failing to inform her that representations made by representative that plaintiff's surgery was covered was not binding on defendant and by failing to advise plaintiff as to alternative means to obtain definitive determination about coverage question in advance of plaintiff's surgery. Ct also found, though, that plaintiff's requested relief of compensatory damages for costs of surgery may not be viable under section 1132(a)(3) of ERISA, which provides for only equitable relief, and that Dist. Ct. properly entered summary judgment in favor of defendant on plaintiff's collateral estoppel count where record showed that plaintiff failed to give representative all material facts before obtaining opinion that surgery was covered.

Dist. Ct. did not err in granting defendant-welfare benefit plan's motion for summary judgment in ERISA action alleging that defendant improperly denied plaintiff's application for long-term disability benefits after invoking pre-existing condition exclusion. Plaintiff's heart attack that precipitated instant claim was related to plaintiff's extensive history of heart disease that was present during relevant look-back period. Plaintiff's extremely high blood pressure during relevant period also disqualified him from said benefits.

Dist. Ct. did not err in affirming ALJ's denial of claimant's application for Social Security disability benefits based on claimant's loss of partial use of one arm. ALJ could properly find that claimant's injury was not severe enough to prevent him from performing light duty work and was not required to give controlling weight to treating physician's contrary opinion since said opinion was not supported by medically acceptable clinical and laboratory diagnostic techniques to document any of claimant's symptoms that would prevent him from working. Moreover, ALJ could discount claimant's contention that he suffered from extreme pain where medical records did not show that claimant made similar claim.