2007 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 5-21-2007 

# D eLong v . Aetn a Li fe Ins C o 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 . 06-1879

F o llow thi s and a dd it ion al work s at : http://d i git alc ommon s .l a w . vi ll anova . e du/thir dc ir c uit_2007

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

w Di git al Reposit ory

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w Di git al Reposit ory

. F or mor e inform at ion, p le as e c ont a ct Be n j amin . C arl s on@l a

w . vi ll anova . e du . Re c omme nde d C it at ion " D eL on g v . Ae tn a L i fe In s C o " (2007). 2007 D e cisio n s . P ape r 1081. http://d i git alc ommon s .l a

w . vi ll anova . e du/thir dc ir c uit_2007/1081D eLong ori gi nal l yt erm ed hi s caus e of a ct i on a br eac h of contr act . H ow ever , as 1 A e tn a p o in ted o u t in its a n sw e r to th e c o m p lain t, D e L o n g ’s c laim is p ro p e rly c h a ra c te ri z e d a s a c la im f o r d e n ia l o f

b e n e f its u n d e r E R IS A , 2 9 U .S .C . § 1 1 3 2 (a )( 1 )( B ).

NOT P RE CE DE NT I AL UN I TED STATES CO UR T OF A PP EALS F O R T H E T H IR D C IR C U IT N O . 06- 1879

________________ J OHN DE L ONG, A ppel l ant v. AE T NA L I F E I NS UR ANC E CO M P ANY

____________________________________ O n A p p ea l Fro m the U n it ed S tat es D istri ct C o u rt F o r th e E a ste rn D istric t o f P e n n sy lv a n ia ( D . C . C i v. N o. 05- cv- 03371) D i s tr i ctJ udge: H onor abl e C ynthi a M . R ufe

_______________________________________ Subm i t t ed U nderT hi r d C i r cui tL A R 34. 1( a)

A PR I L 20, 2007 Be f o r e : SLOV I TER, M CK EE AN D A M BRO , CI RCU I T J UD GES

( Fi l ed M ay21, 2007)

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OP I NI ON

_______________________ P E R C UR I AM J ohn D eLong sued A etna Li fe I ns ur ance C om pany( “A etna”) , cl ai m i ng thatA etna im p ro p e rlyter m in a ted h is d isa b ili tyb e n e f its. A e tn a m o v e d f

o r su m m a ryju d g m e n t, 1D eLong di d notchal l enge the cha r act er i zat i on of hi s cl ai m i n the D i s tr i ctC our t , and now

d e s c ri b e s h is c la im a s o n e u n d e r § 1 1 3 2 (a )( 1 )( B ) ( A p p e lla n t’ s B ri e f 1 9 ). W e r ej ectD eLong’s cl ai m ( A ppel l ant ’ s B r i ef 27) thatA etna had s om e ul t er i or 2 m ot i ve or“bene fi ci al i nt er es t ” i n s t oppi ng di s abi l i typaym ent s t o D eLong. A s D eLong co n ce d es, A etna ad m inist ere d the p lan w h il e h is fo rm er e m p loy er f u n d ed it . (A p p ell an t’ s B r i ef 29. ) A ccor di ngl y , the hei ght ened s crut i nyr equi r ed w hen a c om panyboth funds and ad m inist ers b en ef

it s, see P into v . R eli an ce S td. L ife In s. C o . , 2 1 4 F . 3 d 3 7 7 , 3 8 7 (3d C ir . 2 w hich the D i stri ctC ou rtgrant ed. D eL on g ap peals . W e exe r ci s e j ur i s di ct i on under28 U . S. C . § 1291. O urr evi ew i s pl enary , i ncl udi ng ourcons i der at i on of w hetherthe D i s tr i ctC our templ oy ed the pr opers t andar d t o r evi ew A etna’ s di s abi l i tydet erm i nat i on. See A br amson v. W i l l i am P at er s on C ol l ege, 260 F. 3d 2 6 5 , 2 7 5 (3d C ir . 2 0 0 1 ); E ll is v. L ibertyL ife A ssu r. C o . , 3 9 4 F . 3 d 2 6 2 , 2 6 9 (5th C ir . 2 0 0 4 ). W e fi r s thol d t hatthe D i s tr i ctC our tdi d noterri n r evi ew i ng A etna’ s deni al of D eLong’s cl ai m forabus e of di s cr et i on orforan arbi tr aryand capr i ci ous deci s i on. A n a rb itrar ya n d c a p ric io u s s tan d a rd a p p lies if a p lan g iv e s a n a d m in istra to r d isc re tio n in m aki ng el i gi bi l i tydeci s i ons , unl es s the per s on chal l engi ng the dec i s i on s how s thatthe e x e rc is e o f

d is c re tio n h a s b e e n ta in te d b ya c o n f lic t o f in te re s t o r o th e rw is e . S ee F i res t on e T i re & R ub ber C o. v. B ruch, 48 9 U . S . 10 1, 11 5 (198 9); G i l l i s v. H oech st C el anes e C orp. , 4 F. 3d 1137, 1141 ( 3d C i r . 1993) ; K os tr os i t s v. G A T X C orp. N onC o n tr ib u to ry P e n s io n P la n f o r S a la ri e d E m p lo y e e s , 9 7 0 F .2 d 1 1 6 5 , 1 1 7 3 (3 d C ir . 1 9 9 2 ). T he part i es agr ee thatthe pl an ati s s ue gi ves A etna di s cr et i onaryauthor i tyt o deci de cl ai m s, and D eL on g rai ses no i nference o f a co nfli ctof int eres t . D eL on g m ai ntai ns, 22 0 0 0 ), i s u n w a rr a n te d . 3

h o w e v e r, t h a t A e tn a ’s d e c is io n w a s a rb itr a ry a n d c a p ri c io u s . W e c o n c lu d e , h o w e v e r, th a t A e tn a ’s d e c isio n to ter m in a te D e L o n g ’s d isa b ili ty paym ent s w as notarbi tr aryand capr i ci ous . U nderthe arbi tr aryand capr i ci ous s t andar d of r evi ew , a courtm ayoverturn t he dec i s i on of a pl an admi ni s tr at oronl yi f i ti s “‘ w i thout r e a s o n , u n s u p p o r t e d b y s u b s t a n t i a l e v i d e n c e , o re rr o n e o u s a s a m a t t e ro f l a w . ’ ” A b n t h ya v. H offman- L aR oche, I nc. , 2 F. 3d 40, 45 ( 3d C i r . 1993) ( ci t at i ons om i t t ed) . T he narr ow s cope of r evi ew di s al l ow s a courtfr om s ubs t i tut i ng i t s ow n j udgm entfora r at i onal deci s i on m ade bythe pl an admi ni s tr at or . See i d. W e eva l uat e the dec i s i on t o deny benef i t s agai ns tthe r ecor d avai l abl e t o the pl an admi ni s tr at or . See K os hi ba v. M er ck & C o ., 3 8 4 F .3 d 5 8 , 6 9 (3 d C ir . 2 0 0 4 ). A s the D i s tr i ctC our tnot ed, the pl an admi ni s tr at orw as fac ed w i th confl i ct i ng evi dence r egar di ng D eLong’s di s abi l i ty . D eLong’s tr eat i ng phy s i ci an di agnos ed hi m as perm anen t l ydis abled becau se of m ult i ple herniat i on s, bu l ging dis cs, st eno si s, oes t eophyt es , bodyi m pi ngement , and t orn m eni s ci . ( Supp. A pp. 00308- 11. ) H e not ed thatD eLong w as unabl e t o s i t , s t and, orw al k form or e than 15 mi nut es , and thatD eLong coul d notcl i m b, s quat , orkneel . ( I d. at00310. ) D eLong re por t ed “pr ettycons t antpai n” and the i nabi l i tyt o s i tors t and fora l ong t i m e. ( I d. at00317- 18, 00342. ) H e s t at ed that he us ed one c ane a thom e and tw o cane s out s i de hi s r es i dence . ( I d. at00341. ) D eLong no t ed thathe co uld w al k fo r about 15 m i nu t es ata t i m e, st and , ascend and descen d st ai rs ,4

o c c a sio n a llyb e n d a t th e w a ist in m o d e ra tio n , an d d riv e . (Id . at 0 0 3 4 2 -4 3 .) O rth o p e d ists wh o m De Lo n g c o n s u l t e d f o rb a c k a n d l e g p a i n c o n c l u d e d th a tDe Lo n g s u f f e r e d f r o m a co m b ination o f d eg en era ti v e d isc d isease an d sp inal sten o sis, as w ell as se v ere degene r at i ve j oi ntdi s eas e of the knee s . ( I d. at00377- 83, 00402. ) T he doct orr evi ew i ng D eLong’s M R I r es ul t s forone orthopedi s tdet erm i ned thatD eLong suff er ed fr om “dege ner at i ve di s cogeni c cha nges of the l um bars pi ne w i th s pi nal s t enos i s demonstr at ed at m u lt iple leve ls. ” (Id . at 00 3 8 4 . ) A e tn a e n g a g e d th e s e rv ic e s o f a n in v e s tig a to r t o c o n d u c t s u rv e illa n c e o n D e L o n g . O n fo ur day s i n Jun e 20 04 , an invest i gatorst aked ou tD eL on g’s hom e and otherw i se obs erved hi s act i vi t i es . ( Supp. A pp. 00345- 54. ) O n one day , the i nves t i gat ordi d notfi nd D eLong athi s hom e i n Phi l adel phi a. ( I d. at00346- 47. ) T ol d bya nei ghborthatD eLong had a f ami l yhom e i n W i l dw ood, N ew J er s ey , the i nves t i gat orl ooked ther e, butt o no avai l . ( I d. ) O n t he s econd da yof s ur vei l l ance , the i nves t i gat ordi d nots ee D eLong, and assu m ed that D eL o n g w as c o n fin ing h is acti v it ies t o h is r esid en ce . (Id. at 00 3 4 7 -48 . ) H o w e v e r, o n th e th ird d a y , the in v e stig a to r w a tch e d D e L o n g w a lk f ro m h is h o m e to h is car , dr i ve appr oxi m at el y100 m i l es t o W i l dw ood, exi thi s vehi cl e, w al k al ong the s i de of, and t o the entr ance of, the s hor e home w i thoutbr ace s oror thopedi c s uppor t . ( I d. at 00348- 50. ) W hen D eLong l eftthe home and goti nt o hi s car , and on D eLong’s r eturn, t he i nves t i gat orobt ai ned thr ee mi nut es of s ur vei l l ance vi deo. ( I d. at00349- 50. ) O n the fol l ow i ng day , the fourth and l as tdayof s ur vei l l ance , the i nves t i gat orobs erved D eLong5

s i t t i ng on hi s fr ontpor ch, m ovi ng hi s arm s and hands and occ as i onal l ybendi ng fr om t he w ai s tw hi l e he s poke t o t w o vi s i t or s , and br i efl ys t andi ng tw i ce, once l i ft i ng hi s r i ghtl eg t o pl ace hi s footon hi s chai r , and once l i ft i ng hi s l eftl eg t o pl ace hi s footon the arm of the cha i r , befor e s i t t i ng agai n. ( I d. at00351. ) T he i nves t i gat oral s o s aw D eLong, w i thout b rac es, ortho p ed ic su p p o rt , o r ap p are n t difficu lty , w alkin g fro m h is po rch to h is car, sta n d in g in d if

f e re n t p o sitio n s o n h is p o rc h , at o n e p o in t sw in g in g h is h ip s f ro m f ro n t to back , w al king t o the back of the ho use, and cl i m bing and descen ding t he o uts i de st ai rcas e of anotherr es i dence . ( I d. at00351- 54. ) T he i nves t i gat orvi deot aped D eLong for21 m inu tes. (Id. at 00 3 5 4 . ) I n deny i ng benef

i t s t o D eLong, A etna r el i ed on the obs ervat i ons of i t s i nves t i gat or as w el l as an i ndepende ntm edi cal eval uat i on byD r . C ar l H uff. A ft err evi ew i ng D eL o n g ’s m ed ical reco rds a n d A etna ’s i n v esti g ati v e re p o rt , H u ff d esc ri b ed D eL o n g ’s s pi nal s t enos i s as “an i m agi ng phenomenon t hatdoes notcorr el at e w i th anyi ndi cat i on of neu ral com press i on , no r anyneu ral i nv olvem ent, or anysci at i c pain at tri bu t able t o these im a g in g f

in d in g s.” (S u p p . A p p . 0 0 4 1 4 .) C o m p a rin g D e L o n g ’s d e sc rip tio n s o f h is sy m p to m s a g a in st h is d o c to rs’ f in d in g s, a s w e ll as D e L o n g ’s a b ili tyto a m b u late e a sily and dr i ve fortw o hour s w i thoutappar entdi ffi cul ty , H uff c oncl uded that“ther e i s no in d ica tio n th a t [ D e L o n g ] h a s s u f f e re d a n yn e u ro lo g ic c o n se q u e n c e th a t w o u ld m a k e h im f u n c tio n a lly d is a b le d to w o rk .” (I d . a t 0 0 4 1 5 .) I n s um , al though t he evi dence of D eLong’s di s abi l i tycutboth w ay s , A etna di d notT o the e x tent that D eL o n g inco rpo rates an arg u m en t th at he w as e n ti tl ed to a ju ry 3 tr i al underthe Seventh A m endment , w e not e thathe br oughtan equi t abl e ca us e of a ct i on forw hi ch ther e i s no r i ghtt o a j urytr i al . See Pane v. R C A C orp. , 868 F. 2d 631, 636 ( 3d C i r . 1989) . W e al s o not e thatw e have hel d thata Seventh A m endmentr i ghtt o a j uryt r i al is no t violated b ysu m m aryjud g m en t “so lon g as th e p erso n h av ing the righ t t o the ju ry tr i al i s an ac tual part i ci panti n t he s um m aryj udgm entpr ocee di ng. ” I n r e TM I L i t i g. , 193 F .3 d 6 1 3 , 7 2 5 (3 d C ir . 1 9 9 9 ). ( c ita tio n s o m itte d ). 6 actarbi tr ar i l yorcapr i ci ous l yw hen i tdeni ed D eLong’s cl ai m i n r el i ance on H uff’ s r evi ew of the r ecor d and i t s ow n s ur vei l l ance r eport s , i ncl udi ng s hor ts egment s of vi deot aped foot age. A m ong ot herthi ngs , H uff c oncl uded thatD eLong desc r i bed hi s s ym pt om s i n a m a n n e r i n c o n s is te n t w ith th e re s u lts o f m e d ic a l e x a m in a tio n s a n d o b s e rv e d a c tiv itie s . A l s o, the fi ndi ngs of i nves t i gat i ve r eport , i ncl udi ng the vi deot aped s ur vei l l ance , contr adi ct ed D eLong’s pr i m aryphy s i ci an’ s char act er i zat i on of D eLong’s phy s i cal in f irm a ties , as w e ll as so m e o f D e L o n g ’s o w n sta tem e n ts a b o u t th e se v e rityo f h is d is a b ility. T h e re f

o re , A e tn a ’s d e c is io n w a s n o t ir ra tio n a l o r u n s u p p o rt e d . L as t l y , w e r ej ectD eLong’s ar gum entthathi s cons t i tut i onal r i ght s w er e vi ol at ed b e c a u s e h i s c l a i m w a s d e c i d e d o n s u mm a ryj u d g me n ti n s t e a d o f a f t e ra tr i a l . “ [ A]

3 l i t i ganti s not‘ depr i ved’ of a tr i al . . . upon gr antof s um m aryj udgm entw hen the evi dence of r ecor d atthe t i m e of the mot i on s uppor t s i t s opponenton al l keyi s s ues and the nonmovantfai l s t o puti n s uffi ci entevi dence t o cr eat e a tr i abl e i s s ue of mat er i al fac t . ” A v ia G rou p Int’l , Inc . v . L . A . G ea r C ali fo rnia, Inc., 8 5 3 F . 2 d 1 5 5 7 , 1 5 6 1 (F ed . C ir . 1 9 8 8 ). F o r t h e f

o re g o in g re a s o n s , w e w ill a f f ir m th e D is tr ic t C o u rt ’s ju d g m e n t.