2009 D e c i sion s O p inion s of the U nit e d S t at e s C our t of Appe al s for the Thir d C ir c uit 2-20-2009 

# E vans v . Empl B e nefit P r e c e de nt i al or N on-P r e c e de nt i al : N on-P r e c e de nt i al D ocke t N o . 07-3552

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Thi s de c i sion i s br ou ght t o you for f r e e and ope n a c c e s s b y the O p inion s of the U nit e d S t at e s C our t of Appe al s for the Thir d C ir c uit at V i ll anova U nive r sity S choo l of L a

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w . vi ll anova . e du . Re c omme nde d C it at ion " E van s v . E mp l Be nefit " (2009). 2009 D e cisio n s . P ape r 1846. http://d i git alc ommon s .l a

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_____________ LI SA A . EV A N S, A ppel l ant

v. E M P L OYE E BE NE F I T P L AN, C A M P D R E S S E R & M C K E E , IN C .; C A M P D R E S S E R & M C K E E , IN C .; CA M P D RE SSER & M CK EE, I N C. BO A RD O F D I RE CT O RS; M E T RO P OL I T AN L I F E I NS UR ANC E CO M P ANY

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forthe D i s tr i ctof N ew J er s ey ( D . C . C i vi l N o. 03- cv- 04915) Di s tr i c tJ u d g e : Ho n o r a b l e Re n e e M . Bu mb

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on February2, 2009 B efore: R E N D E L L , JO R D A N , and R O T H , C i rcui tJudg es.

( Fi l ed: February20, 2009)

__________ OPI NI ON O F THE COURT

__________E vans s aw s ever al phy s i ci ans : D r . R obi n G r os s , a pul m onol ogi s t ; D r . N ancy 1 B eggs , an i nt erni s t ; and D r . M ar l a Ti ffa ny , an al l er gi s t . D r . G r os s ’ s M ar ch 1, 2000, rep o rtto D r. B eg g s said that E v an s’s h ist o ryan d a p o sit ive m etha ch o li n e c h all en g e w ere cons i s t entw i th as thm a, and not ed thatE vans w or ked as an envi r onm ent al engi neerand had bee n expos ed t o fum es . A ft eraddi t i onal offi ce vi s i t s , D r . G r os s r eport ed thatE vens had neve rhad s ym pt om s i n t he fi el d oraft ercomi ng hom e fr om w or k, and thats he had r eport ed naus ea a s a s ym pt om of herl as tepi s ode, w hi ch w as i ncons i s t entw i th as thm a but m ig h t p o in t to a v ira l ca u se . D r. G ro ss re c o m m e n d e d th a t E v a n s c o n tin u e to u se F lo v e n t, S e re v e n t, an d S in g u lair, b u t n o ted th a t h e r a sth m a d id n o t ap p e a r to b e o c c u p a tio n a l, becau se E van s had o ther tri gg ers and sym ptom s unco nn ect ed w i th h er w ork. D r. G ross di s cus s ed w i th E vans thats om e of he rs ym pt om s m i ghtbe r el at ed t o anxi ety , and Evans beca m e veryagi t at ed and ups et . D r . T i ffa nydi agnos ed Evans w i th as thm a butm ade no obj ect i ve fi ndi ngs . She putno l i m i t s on E vans ’ s phy s i cal capa bi l i t i es , and not ed thats he coul d r i de 100 mi l es on a bi ke. D r . T i ffa nyr ecomm ended thatE vans r eturn t o w or k but avo i d w ork i n the fi el d. D r. B egg s t old D r. T i ffan ythat the eti ologyof E van s’ s i l l ness r emai ned unknow n, butr ecomm ended thatE vans avoi d as thm a tr i gger s and occ upat i onal e x p o s u re s . 2 R E N D E L L , C i r cui tJ udge. T hi s cas e conc erns the deni al of Long T erm D i s abi l i ty( “LT D ”) benef i t s t o the p l a i n t i f f , Li s a Ev a n s , wh o wo r k e d a s a n e n v i r o n me n t a l e n g i n e e rwi th d e f e n d a n tCa mp D r es s er& M cK ee ( “C D M ”) . D efe ndantM etr opol i t an Li fe I ns ur ance C om pany ( “M et L i fe” ) admi ni s t er ed C D M ’ s di s abi l i tyi ns ur ance pl an ( the “Pl an”) . E vans r ece i ved Shor tT erm D i s abi l i tybenef i t s aft ercompl ai ni ng of s hor tnes s of br eath and r ece i vi ng an i ni t i al di agnos i s of as thm a. M et L i fe de ni ed hercl ai m forL T D benef i t s on M ay24, 2000, af ter E v an s’s p u lm o n o log ist , D r. G ross , rep o rt ed that sh e w as n o t con v ince d that E v an s’s c o n d iti o n w a s w o rk re late d , tha t th e a sth m a w a s w e ll co n tro lled o n m e d ica tio n , an d th a t it w a s s a f e f o r E v a n s to re tu rn to w o rk . E v a n s a p p e a led . M e tL if e d e c lin e d to re v e rse its 13

d ec isi o n , cit ing D r. G ross ’s op inion an d o ther m ed ical i n fo rm ati o n ind icati n g that E v an s’s a s th m a w a s n o t d is a b lin g . E vans fi l ed s ui tagai ns tboth C D M and M et L i fe i n the D i s tr i ctC our tforthe D i s tr i ctof N ew J er s eyon O ct ober17, 2003. T he D i s tr i ctC our thad j ur i s di ct i on overt he case pu rs uan tt o E R ISA , 28 U . S . C . § 1 13 2(e) . T he D i stri ctC ou rtgrant ed the defen dan t s’ m ot i ons fors um m aryj udgm entand deni ed Evans’ s m ot i on fors um m aryj udgm enton J u l y3 0 , 2 0 0 7 . We h a v e j u r i s d i c t i o n o v e rth e a p p e a l u n d e r2 8 U . S . C . § 1 2 9 1 . We exerci se pl enaryrevi ew ov er s um m aryj ud gm ent deci si on s.

I. Is C D M a p ro p er d efe n d a n t? In a c laim f

o r w ro n g f

u l d e n ial o f

b e n e f its u n d e r E R IS A , the p ro p e r d e f e n d a n t is the pl an i t s el f ora per s on w ho contr ol s the admi ni s tr at i on of bene fi t s underthe pl an. 29 U .S .C . § 1 1 3 2 (a )(1 )(B ). E v a n s a rg u e s th a t C D M sh a re d d isc re tio n a rya u th o rityw ith M e t Li f e t o i n t e rp r e tth e P l a n , d e t e r mi n e e l i g i b i l i tyf o rb e n e f i t s , a n d ma k e c l a i ms d e c isio n s. C D M sa y s th a t ith a d n o su c h a u th o rity , an d th e re f o re c a n n o t b e su b

jec t to liab ili ty . T h e D istric t C o u rt h e ld th a t C D M w a s n o t a p ro p e r d e f e n d a n t. E van s point s t o tw o sect i on s of t he P l an to supp orther posi t i on that C D M i s a pr operdefe ndant : fi r s t , the “St at ementof ER I SA R i ght s , ” w hi ch s ay s “Y ou have the ri g h t t o h av e the P lan a d m inistrator rev iew an d rec o n side r y o u r claim . ” (A p p . 1 1 0 . ) A nothers ect i on of the Pl an s ay s that“[i ] n carry i ng outthei rr es pect i ve r es pons i bi l i t i es4

u n d er the P lan, th e P lan a d m inistrator an d o ther P lan f idu ciaries sh all h av e d iscreti o n ary author i tyt o i nt erpr etthe t erm s of the Pl an and t o det erm i ne el i gi bi l i tyforand ent i t l ement t o Pl a n b e ne fi t s i n a c c or da nc e w i th the t e r ms o f the Pl a n. ” ( A pp . 10 9. ) I n the ER I SA i nform at i on s ect i on, C D M i s l i s t ed under“N ame and A ddr es s of Em pl oy erand Pl an A dm i ni s tr at or . ” Thi s , E vans ar gues , s how s thatC D M i s a pl an admi ni s tr at orand a pr oper d e f e n d a n t. C D M p o in ts o u t th a t th e P lan sp e c if ica llyd e leg a tes to M e tL if e th e d isc re tio n to det erm i ne el i gi bi l i tyforbenef i t s : “M et L i fe i n i t s di s cr et i on has author i tyt o i nt erpr ett he t erm s , condi t i ons , and pr ovi s i ons of the ent i r e contr act . ” ( A pp. 86. ) I tar gues thatthe S tate m e n t o f

E R IS A R ig h ts is a g e n e ric sta tem e n t re q u ire d b yf e d e ra l law , an d n o t a s u b s ta n tiv e c o n tr a c t p ro v is io n . See C r uthis v. Metr opol i tan Li f e I ns . C o. , 356 F. 3d 816, 818 ( 7th C i r . 2004) . C D M al s o poi nt s outthatthe “r es pect i ve r es pons i bi l i t i es ” port i on of th e d i s c r e t i o n a r ya u th o r i tys e c t i o n d o e s n o ts u p p o r tE v a n s ’ s c o n t e n t i o n th a tCD M d e te rm in e s e lig ib ility f

o r b e n e f its . E xer ci s i ng contr ol overthe admi ni s tr at i on of bene fi t s i s the def i ni ng fea tur e of the p r o p e rd e f

e n d a n tu n d e r2 9 U. S . C. § 1 1 3 2 ( a ) ( 1 ) ( B) , a n d E v a n s h a s n o ts h o wn th a tCD M has anyauthor i tyorr es pons i bi l i tyforadmi ni s t er i ng benef i t s underthe Pl an. T he us e of C D M ’ s addr es s i n t he cont acti nform at i on for“Em pl oy erand Pl an A dm i ni s tr at or ” does n o t s h o w th a t C D M h a s d is c re tio n to d e te rm in e e lig ib ility. See C ur ci o v. John H ancock Li f e I ns . C o. , 3 3 F .3 d 2 2 6 , 2 3 3 (3 d C ir. 1 9 9 4 ); s ee al s o D ani el

v. E at on C or

p. , 839 F. 2d5

263, 266 ( 6th C i r . 1988) ( “U nl es s an empl oy eri s s how n t o contr ol admi ni s tr at i on of a p lan, i t i s n o t a pro p er p artyd ef en d an t i n an ac ti o n co n ce rnin g b en ef it s. ”). T h e P lan’s lang u ag e m ak es itclea r th at M etL ife, no t C D M , h as d iscreti o n to interp ret th e c o n tr ac t’ s t erm s . E vans i s corr ectthatthe Pl an does nots peci fi cal l ygi ve M et L i fe exc l us i ve d isc re tio n , b u t sh e h a s p re se n ted n o e v id e n c e th a t C D M h a d a n yro le in b e n e f its det erm i nat i ons . I ndeed, hercomm uni cat i ons aboutthe Pl an dur i ng the per i od s he w as s eeki ng di s abi l i tybenef i t s w er e di r ect ed t ow ar d M et L i fe, notC D M . C D M w as not re sp o n sib le f

o r a d m in iste rin g b e n e f

its o r d e ter m in in g e lig ib ili ty , an d th e re f o re is n o t a p ro p e r d e f

e n d a n t. W e w ill a f

f irm th e D istric t C o u rt’s g ra n t o f su m m a ryju d g m e n t to C D M.

II. M etL if e’s D en ial of B en efits U n d er F i r es t one Ti r e & R ubberC o. v. B r uch , 489 U . S. 101, 115 ( 1989) , i f the E R IS A p la n g iv e s th e a d m in is tr a to r d is c re tio n to in te rp re t th e te rm s o f th e b e n e f

it p la n , a cou rtrevi ew s the ad m i nis trat or’ s deci si on for abu se of d i scr et i on . T he P l an in this case g ra n ts M e tL if

e su c h d isc re tio n a rya u th o rity : “M e tL if e in its d isc re tio n h a s a u th o rityto interpre t th e term s, co n d it ion s, an d p rov isi o n s o f th e e n ti re c o n tr ac t. ” (A p p . 8 6 . ) R ece nt l y , the Supr eme C our topi ned i n Met Li f e v. G l enn , 1 2 8 S . C t. 2 3 4 3 (20 0 8 ), that w h ere there is a co n fli ct of interest un d er F i r es t one w h e n a p lan a d m in istra to r b o th eval uat es cl ai m s forbenef i t s and pay s thos e cl ai m s , the di s tr i ctcourts houl d w ei gh theSee, e. g. , U n itedS ta tes v . P a trin , 575 F. 2d 708, 712 ( 9th C i r . 1978) ( hol di ng thatan 2 appel l at e courtm ayheara new i s s ue r es ul t i ng fr om a r ece ntchange i n the l aw as l ong as the partyagai ns tw hom the i s s ue i s r ai s ed i s notpr ej udi ced a nd w oul d nothave tr i ed the c a se d if f e re n tly ); see al

so S in g leto n v . W

u lff , 428 U . S. 106, 121 ( 1976) ( “The m att erof w hatques t i ons m aybe t aken up a nd r es ol ved forthe fi r s tt i m e on appe al i s one l eft pr i m ar i l yt o t he di s cr et i on of the court s of appe al s , t o be exe r ci s ed on the fa ct s of ind ividu al ca ses. . . . C ertainlythere are circu m stan ce s in w h ich a fe d era l app ell ate c o u rt is ju stif ied in re so lv in g a n iss u e n o t p a ss e d o n b e lo w , as w h e re th e p ro p e r re so lu tio n is bey ond anydoubtorw her e i nj us t i ce mi ghtotherw i s e r es ul t . ”) ( i nt ernal quot at i ons o m itted). 6 c o n f lic t o f in te re s t a s o n e f

a c to r i n d e te rm in in g w h e th e r t h e re w a s a n a b u s e o f d is c re tio n . 1 2 8 S . C t. at 2 3 5 1 -5 3 . O u r p re v io u s ju risp ru d e n c e h a d in stru c ted th e d istric t co u rt to a p p ly a “ h e ig h te n e d s ta n d a rd o f re v ie w ” o r “ h e ig h te n e d s c ru tin y ” in s u c h c a s e s . See P i nt o v. R el i ance Standar d Li f e I ns . C o. , 2 1 4 F .3 d 3 7 7 , 3 8 7 (3 d C ir . 2 0 0 0 ). H er e, M et L i fe both eval uat es and pay s cl ai m s underthe Pl an, and al l part i es ac k n o w ledg ed that su ch a d u al role c rea ted a co n fli ct. T h e D istri ct C o u rt , ac ti n g b ef o re publ i cat i on of the G l enn deci s i on and i n acc or dance w i th P in to , appl i ed a he i ght ened s t a n d a r d o f

r e v i e w. We wi l l a p p l yth e n e w s t a n d a r d o u r s e l v e s o n a p p e a l , u n l e s s we bel i eve thatr emand i s nece s s aryt o avoi d pr ej udi ce. H er e, the hei ght ened r evi ew appl i ed 2 bythe D i s tr i ctC our tw as m or e fa vor abl e t o the pl ai nt i ff than the new s t andar d, s o w e fi nd no pr ej udi ce t o heri n ourcons i der i ng thi s appea l us i ng the G l enn s t andar d w i thout re m a n d in g . E ven w i th P in to ’s he igh tene d stan d ard , the D istri ct C o u rtfo u n d that M etL ife’s d e n ial o f b e n e f its w a s re a so n a b le a n d su p p o rte d b ysu b sta n tial e v id e n c e . T h e c o u rt h e ld7

that M etL ife’s d ec isi o n w as b ase d o n the o b jecti v e m ed ical reco m m en d ati o n s o f E v an s’s tr eat i ng pul m onol ogi s t , D r . G r os s , w ho cl ear ed Evans t o r eturn t o w or k. E vans admi t t ed thatD r . G r os s knew thatE vans ’ s j ob expos ed hert o dus tand fumes. She ar gued that M etL ife sh o u ld h av e g iven m o re w eigh t t o rep o rt s fro m o ther p h y sici an s, b u t th e C o u rt obs erved thatnone of the otherdoct or s E vans cons ul t ed r eport ed anyobj ect i ve et i ol ogy f o r h e r s h o rt n e s s o f

b re a th . E v a n s a lso p o in ted to a n in a c c u ra te in iti a l jo b d e sc rip tio n su b m itt e d b yC D M to M et L i fe w hen s he s oughtShor tT erm D i s abi l i tybenef i t s ( the C D M empl oy ee w ho fi l l ed outthe form ans w er ed “N o” t o an i nqui ryaboutw hetherE vans w as r equi r ed t o “be ex p o sed to d u st, g as, or f u m es” in the co u rse o f h er job ). (A p p . 9 2 0 . ) T h e C o u rt acknow l edged thats uch an i nacc ur acycoul d pot ent i al l yaff ectthe cl ai m deci s i on- m aki ng pr oces s , butconcl uded thatthe i nacc ur at e des cr i pt i on ( m ade be for e Evans r ece i ved her asthm a diagno si s) did not pr ecl ud e a fu l l and fai r r eview of E van s’ s cl ai m , becau se M et L i fe’ s deci s i on w as bas ed pr i m ar i l yon D r . G r os s ’ s r ecomm endat i on, noton the i ni t i al jo b d e s c ri p tio n , a n d D r. G ro s s ’s f in d in g s d e ta ile d E v a n s ’s o c c u p a tio n a l e x p o s u re s . T her e i s no r eas on t o r emand forappl i cat i on of the G l enn st and ard t o the fact s. V i ew i ng the conf

l i ctof i nt er es ther e as one fa ct or , r atherthan appl y i ng a hei ght ened s t andar d of r evi ew , does notal t erthe out come. T he D i s tr i ctC our tcorr ect l yconcl uded th a tM e t Li f

e h a d g i v e n Ev a n s ’ s c l a i m a f u l l a n d f a i rr e v i e w an d th a ti t s d e n i a l o f LTD b en ef it s d id n o t am o u n t t o an ab u se o f d iscreti o n . W e w o u ld af firm the D istri ct C o u rt ’s8

deci s i on, even i f the Supr eme C our thad notcl ar i fi ed i n G l enn thatM et L i fe’ s confl i ct ed pos i t i on does notchange the s t andar d of r evi ew , buti s one of s ever al fac t or s t o be cons i der ed i n a di s tr i ctcourt ’ s r evi ew forabus e of di s cr et i on. W e do s o appl y i ng G l enn a s w e ll. W e w ill a f

f irm th e D istric t C o u rt’s d e c isio n th a t M e tL if e d id n o t ab u se its d is c re tio n in d e n y in g E v a n s ’s L T D c la im .

I I I . Ev a n s ’ s Ot h e r Cl a i ms E vans m akes s ever al ot hercl ai m s , none of w hi ch mer i tful s om e ana l y s i s . E vans p o in ts to a N e w Je rse yre g u latio n th a t d isc re tio n a ryc lau se s a re v o id a s c o n tra ryto p u b lic p o licy , b u t th e re g u latio n is o n lya p p lica b le a s o f Ja n u a ry1 , 2 0 0 8 , an d o n lyp ro h ib its th o s e p ro v is io n s th a t c la im to re s e rv e s o le d is c re tio n to th e c a rr ie r. See N . J . A dm i n. C o d e . § 1 1 :4 - 5 8 .4 . M e tL if e ’s p o lic yd o e s n o t r e s e rv e s o le d is c re tio n . E vans al s o m akes a br eac h of fi duci arycl ai m , buts he ac know l edged i n the D i s tr i ct C our tthatthe cl ai m w as an al t ernat e form of r el i ef t o r ecove rL T D benef i t s . T he S u p re m e C o u rt h a s h e ld th a t “e q u itab le r e lief ” in E R IS A m e a n s a re m e d ytyp ica lly avai l abl e i n equi ty , and thata cl ai m form oneydue undera contr acti s “qui nt es s ent i al l yan act i on atl aw . ” G r eat- W es tLi f e & A nnui t

y I ns . C o. v. Knuds on , 534 U . S. 204, 209- 10 ( 2002) ( quot i ng W

a l-M a rt S to re s, In c . v. W

e lls , 2 1 3 F .3 d 3 9 8 , 4 0 1 (7 th C ir . 2 0 0 0 )) . E v a n s c laim s th a t sh e re q u e ste d a d e sc rip tio n o f b e n e f its f ro m C D M a n d C D M d id9

no tsend itprom ptl y , i n v i olat i on of 2 9 U . S . C . § 1 13 2(c) . C D M had sw i t ched carr i ers j ust befor e Evans’ s r eques tand di d nothave the updat ed bene fi t s des cr i pt i ons bookl et ; i ts ent E vans the pr evi ous pl an’ s bookl etw i th a not e of e xpl anat i on. W hen Evans r eques t ed the u p d ated b o o k let , C D M sen t i t pro m p tl y . T h e D istri ct C o u rtd ec li n ed to im p o se statuto ry p e n a lti e s o n C D M f

o r its a c tio n s, a n d w e w ill n o t d istu rb th a t d e c isio n . A s s u c h , w e w ill n o t add ress C D M ’s st atute o f li m it ati o n s arg u m en ts as to 2 9 U . S . C . § 1 1 3 2 (c). F in a lly , E v a n s a rg u e s th a t th e b e n e f its d e sc rip tio n w a s le g a llyd e f icie n t b e c a u se it di d notpr eci s el ys t at e thats he had a r i ghtnott o have he rL T D benef i t s cl ai m deni ed bas ed on an i nacc ur at e j ob des cr i pt i on. E R I SA r equi r es thata des cr i pt i on m us tbe w r i t t en cl earl yand accurat el y , and m ustbe co m prehen si ve en ou gh t o “reasonab l yapp ri se p a r t i c i p a n t s ” o f

th e i rr i g h t s a n d o b l i g a t i o n s u n d e rth e p l a n . 2 9 U . S . C . § 1 0 2 2 ( a ) . We a g re e w ith th e D istric t C o u rt th a t itw o u ld b e u n re a so n a b le f o r a b e n e f

its d e sc rip tio n to s pel l outeveryconce i vabl e ci r cumst ance i n w hi ch bene fi t s m ayornotbe deni ed, and that th e b e n e f

its d e s c ri p tio n in th is c a s e c o m p lie d w ith E R IS A ’s re q u ir e m e n ts . C oncl usi on F o r th e re a so n s s e t f

o rth a b o v e , w e w ill A F F IR M th e O rd e r o f th e D istric t C o u rt.