Source: https://law.justia.com/cases/federal/appellate-courts/F3/94/644/602543/
Timestamp: 2019-08-21 16:08:37
Document Index: 73647820

Matched Legal Cases: ['§ 1132', '§ 1132', '§ 1133', '§ 1133', '§ 2560', '§ 2560', '§ 2650', '§ 2560', '§ 1133', '§ 1133', '§ 1132']

Thomasine Bridgewater, Plaintiff-appellant, v. Harper Hospital, Defendant-appellee, 94 F.3d 644 (6th Cir. 1996) :: Justia
Justia › US Law › Case Law › Federal Courts › Courts of Appeals › Sixth Circuit › 1996 › Thomasine Bridgewater, Plaintiff-appellant, v. Harper Hospital, Defendant-appellee
Thomasine Bridgewater, Plaintiff-appellant, v. Harper Hospital, Defendant-appellee, 94 F.3d 644 (6th Cir. 1996)
This court reviews an order granting summary judgment de novo. Harrow Prods., Inc. v. Liberty Mutual Ins. Co., 64 F.3d 1015, 1019 (6th Cir. 1995). Summary judgment must be granted "if the pleadings, depositions, answers to interrogatories, and admissions on file, together with the affidavits, if any, show that there is no genuine issue as to any material fact and that the moving party is entitled to judgment as a matter of law." Fed. R. Civ. P. 56(c).
The district court, citing Firestone Tire and Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989), and Davis v. Kentucky Fin. Cos. Retirement Plan, 887 F.2d 689, 694 (6th Cir. 1989), cert. denied, 495 U.S. 905 (1990), applied an abuse of discretion standard, stating that "a court must review a determination made under an ERISA benefits plan which gives discretion to the plan administrator, under the 'abuse of discretion' standard." In Firestone, the Supreme Court held that "a denial of benefits challenged under § 1132(a) (1) (B) is to be reviewed under a de novo standard unless the benefit plan gives the administrator or fiduciary discretionary authority to determine eligibility for benefits or to construe the terms of the plan."7 489 U.S. at 115.
When a plan gives discretion to its administrator, this court applies the "arbitrary and capricious" standard of review. Davis, 887 F.2d at 693-94. In Davis, this court held that the "arbitrary and capricious" standard was properly applied where the plan stated that the administrator's decisions "shall be final, conclusive and binding." Id. at 694; accord Bartling v. Fruehauf Corp., 29 F.3d 1062, 1071 (6th Cir. 1994) (applying "arbitrary and capricious" standard where plan stated that plan administrator's "administration and interpretation of the Plan shall be final and shall be binding and conclusive upon all persons").
Bridgewater's claim for benefits, challenging the decision of the Plan's Claims Review Committee, is pursuant to § 1132(a) (1) (B). The Plan grants discretion to the Claims Review Committee: "Decision of the Claims Review Committee is final." Therefore, the district court's decision, affirming the denial of benefits, must be affirmed if there are no genuine issues of material fact as to whether the Claims Review Committee's denial of benefits was "arbitrary and capricious" and Harper is otherwise entitled to judgment as a matter of law.
Bridgewater contends that the "arbitrary and capricious" standard is equivalent to the "abuse of discretion" standard. It is not. "The arbitrary and capricious standard is the least demanding form of judicial review of administrative action. When it is possible to offer a reasoned explanation, based on the evidence, for a particular outcome, that outcome is not arbitrary and capricious." Davis, 887 F.2d at 693 (citation omitted). An abuse of discretion exists when the reviewing court is firmly convinced that a mistake has been made. Romstadt v. Allstate Ins. Co., 59 F.3d 608, 615 (6th Cir. 1995). That is, even if we are convinced that a mistake has been made, the denial of Bridgewater's benefits must be upheld if it is possible to offer a reasoned explanation for the outcome in this case.
Bridgewater did not raise these procedural claims in the district court. Absent exceptional circumstances, this court will not address an issue not first raised in the district court. See generally Building Serv. Local 47 Cleaning and Contractors Pension Plan v. Grandview Raceway, 46 F.3d 1392, 1398-99 (6th Cir. 1995). But, as this issue has been briefed as completely as possible and its resolution would prevent remand on issues of federal statutory law, this court should resolve these issues. See Katt v. Dykhouse, 983 F.2d 690, 695 (6th Cir. 1992) (court addresses new issue as it was presented with clarity and completeness and its resolution would materially advance progress of already protracted litigation).
Relying on Vanderklok v. Provident Life and Accident Ins. Co., Inc., 956 F.2d 610 (6th Cir. 1992), Bridgewater contends that she did not receive adequate notice of the denial of her claim. In Vanderklok, the court held that a plan administrator's failure to set forth the reasons for a denial of a claim was a procedural error that amounted to "a significant error on a question of law, which requires that the decision to deny benefits be overturned."8 956 F.2d at 616 (citing Wolfe v. J.C. Penney Co., Inc., 710 F.2d 388, 393 (7th Cir. 1983)). The court noted that "the 'reason' given for denial is not a reason, but a conclusion." Id.
The referenced report of Dr. Mendelson states that Bridgewater is not disabled. Unlike the notice in Vanderklok, this notice complied with 29 U.S.C. § 1133 because it "set [ ] forth the specific reasons for [the] denial" and was "written in a manner calculated to be understood by [Bridgewater]."9 956 F.2d at 616.
The minimum standards for compliance with 29 U.S.C. § 1133 are set out at 29 C.F.R. § 2560.503-1. Bridgewater contends that her notice of denial did not comply with § 2560.503-1(e) (1) and (3). Those subsections are implicitly inapplicable to the denial provided Bridgewater because subsection (e) (2) states that if the requirements of those subsections ((e) (1) and (3)) are not met, "the claim shall be deemed denied and the claimant shall be permitted to proceed to the review stage described in paragraph (g) of this section." 29 C.F.R. § 2650.503-1(e) (2). Paragraph (g) requires
Bridgewater contends that she was not provided information as to what steps she should take to perfect her claim as required by 29 C.F.R. § 2560.503-1(f). When Bridgewater's claim was initially denied by Harper's benefits manager, Bridgewater was not provided with this type of information. But, when the Claims Review Committee requested that she undergo a medical examination, Bridgewater "w [as] notified of the deficiencies in [her] claim, and nothing further was required to perfect the claim; thus, no new evidence [was] required." Tolley v. Commercial Life Ins. Co., 1993 WL 524284, * 5 (6th Cir. Dec. 17, 1993), cert. denied, 115 S. Ct. 59 (1994). That is, Bridgewater was required, under the Plan, to demonstrate that she was disabled and failed to do so even after refusing to submit to an examination scheduled by the Claims Review Committee (and offering a report of another doctor). Even if the plan administrator "violated the strict letter of § 1133 and its regulations, it did provide plaintiff [ ] with the necessary information to understand why [her] claims were being denied, the true purpose of § 1133. Thus, this error was not 'significant' and does not require reversal."12 Id.; accord Kreutzer v. A.O. Smith Corp., 951 F.2d 739, 743 (7th Cir. 1991) (requiring bad faith or active concealment of plan provision).
Bridgewater was required, under the Plan, to demonstrate that she was disabled and failed to do so even after refusing to submit to an examination scheduled by the Claims Review Committee (and offering a report of another doctor). Harper has thus met its burden of "offer [ing] a reasoned explanation, based on the evidence, for [this] particular outcome," Davis, 887 F.2d at 693, and the decision to deny those benefits was not arbitrary and capricious.
The Plan provides for benefits to be paid to " [a] Participant whose active employment ... terminates prior to the Participant's sixty-fifth (65th) birthday on account of his Permanent and Total Disability and after he has completed ten (10) or more Years of Service." "Permanent and Total Disability" is defined as "a physical or mental condition ... which prevents the Participant from engaging in any occupation or employment for which he may be suited by education, training or experience, and which, in the opinion of a qualified physician, will be permanent and continuous during the remainder of the Participant's life."
The relevant portion of Section 1132(a) provides, "A civil action may be brought--(1) by a participant or beneficiary ... (B) to recover benefits due to him under the terms of his plan, to enforce his rights under the terms of the plan, or to clarify his rights to future benefits under the terms of the plan...." 29 U.S.C. § 1132(a) (1) (B)
The other cases relied upon by Bridgewater are also distinguishable because those cases involved inadequate notice. See Weaver v. Phoenix Home Life Mut. Ins. Co., 990 F.2d 154, 159 (3d Cir. 1993); Johnson v. Trustees of Western Conference of Teamsters Pension Trust Fund, 879 F.2d 651, 654 (9th Cir. 1989); Bogue v. Ampex Corp., 750 F. Supp. 424 (N.D. Cal. 1990)