Opinion ID: 710225
Heading Depth: 2
Heading Rank: 3

Heading: The Decision was Arbitrary and Capricious

Text: 28 In reviewing the administrator's decision deferentially, a district court must consider whether the decision was based on a consideration of the relevant factors. Jordan v. Retirement Comm. of Rensselaer Polytechnic Inst., 46 F.3d 1264, 1271 (2d Cir.1995) (quotations omitted). A denial of a claim challenged under Sec. 502(a)(1)(B) is arbitrary and capricious if there has been a clear error of judgment, id. (quotation omitted), that is, if the decision was  'without reason, unsupported by substantial evidence or erroneous as a matter of law,'  Pagan, 52 F.3d at 442 (quoting Abnathya, 2 F.3d at 45). Substantial evidence in turn is such evidence that a reasonable mind might accept as adequate to support the conclusion reached by the [decisionmaker and] ... requires more than a scintilla but less than a preponderance. Sandoval, 967 F.2d at 382 (quotations omitted). 29 In reviewing the Trustees' decision under the arbitrary and capricious standard, as our de novo review of the district court's decision requires, we find that the denial of the claim was not supported by substantial evidence. We have no basis for concluding that the Trustees' decision rested on anything other than the three-sentence report. Reliance on such limited information to deny the claim was arbitrary and capricious since it was not based on a consideration of the relevant factors. See Jordan, 46 F.3d at 1271 (quotation omitted). Moreover, even if Byrne had explained in detail the contents of the administrative record--Blake's letter, the nursing notes, and Aetna's claim analysis and denial--each item either buttressed Miller's position or was neutral. We examine each piece of evidence in turn. 30 First, as Judge Bartels found, the nursing notes could not have been evidence in favor of the Fund's decision since the Trustees at best gleaned no information from them and at worst did not understand them. In reviewing the denial of Potok's claim, the subcommittee did not actually examine the nursing notes; rather, it relied on the summary provided by Byrne. As Byrne's deposition indicates, however, he found no evidence in the notes to justify the Fund's ultimate denial of the claim. While Byrne first stated that the notes supported the Fund's conclusion in part, Byrne later testified that he did not really reach any conclusions or obtain any information on the basis of the nursing notes, which at best he understood somewhat or could not understand at all. 31 A Fund employee, Pat Komoroski, who was neither a nurse nor a physician, also reviewed the notes in preparation for the meeting with the Trustees. However, she did not testify and Byrne could not recall whether she understood the notes. He had no knowledge as to whether anyone who interpreted the notes for the Trustees received any assistance in understanding them. Thus, without such interpretation, the nursing notes were useless to the Trustees. 32 Even if the notes had been explained adequately to the Trustees, they do not lend support to the Trustees' position. While the Fund may be correct in stating that the notes do not prove the medical necessity of private nursing, the notes do not support the conclusion that the nursing care was not necessary. In particular, they offer no indication as to the availability and ability of the Hospital's nurses to provide the same level of care that Potok received from the private duty nurses. Thus, we find the notes nondeterminative. 33 Second, we find that Dr. Blake's letter did not support the Board's conclusion. While the letter did not use the term medically necessary, it plainly reflects Dr. Blake's belief that the private duty nursing care was necessary. Dr. Blake pointed out the severe complications of Potok's post-operative care, thus distinguishing Potok's case from that of the typical patient recovering from coronary artery bypass surgery. He noted that [b]ecause of the severity of her illness, the medical team recommended the nursing care. Moreover, his language suggests that were it not for the private nursing, Potok would not have made a meaningful recovery [with the prospect of] returning to an active and productive life. 34 This letter leads only to the conclusion that the private duty nursing care was medically necessary and that such care could not have been provided by the Hospital nurses. It contains the professional opinion of an expert who knew Potok's medical condition extremely well and it expresses the views not only of Dr. Blake but also of the medical team at the Hospital. It is reasonable to assume that Dr. Blake and the medical team were well aware of the nature and availability of nursing care at the Hospital and that they believed it would not be sufficient for Potok's particularly egregious condition. 35 Third, the only piece of record evidence supporting the Trustee's decision was Aetna's denial, which was the very decision the Fund was reviewing. The Fund argues that, given its right to consult experts, it should be able to rely on the denial in reviewing the appeal. Yet it offers no evidence to support its implied claim that the Aetna claim reviewer was an expert on the type of care that staff nurses could provide. Moreover, while the Fund was not prohibited from agreeing with Aetna, Aetna's speculation, without supporting medical evidence, is insufficient to justify the Fund's decision. 36 Finally, the Fund defends its decision by contending that underlying all of the evidence is the common-sense conclusion that patients at New York Hospital do not have to hire their own private nurses in order to ensure that they receive the medically required care. In effect, the Fund argues that both common sense and the very decision it was reviewing were sufficient to overcome Dr. Blake's statement that he and the medical team at New York Hospital believed that private nursing care was necessary for Potok's full recovery. We find that the Fund's ipse dixit pronouncement, based simply on New York Hospital's reputation, and Aetna's view of the circumstances were insufficient to contradict the only piece of expert evidence. See Catania v. NYSA-ILA Severance Benefit Fund, No. 91 Civ. 3262, 1992 WL 176502, at  8-9, 1992 U.S.Dist. LEXIS 10985, at  24-27 (S.D.N.Y. July 15, 1992) (finding trustees acted arbitrarily when they denied a claim supported by a treating physician's letter without contradictory medical evidence and based on nothing more than speculation); Pritt v. United Mine Workers of Am., 847 F.Supp. 427, 433 (S.D.W.Va.1994) (finding the denial of nursing benefits unreasonable because the defendants were unable to point to any 'substantial medical evidence' supporting the denial of benefits [and] ... the only substantial medical evidence supports the opposite conclusion). 37 Moreover, as the Fund itself points out, trustees have an affirmative duty to seek expert advice when required. Donovan v. Bierwirth, 680 F.2d 263, 272-73 (2d Cir.), cert. denied, 459 U.S. 1069, 103 S.Ct. 488, 74 L.Ed.2d 631 (1982). If they felt that the Hospital's nurses could have provided the type of care Potok received from the private nurses, it was incumbent upon them to seek the sort of medical evidence that they attempted to introduce at trial to determine whether their speculation was correct. Thus, for the foregoing reasons, we find that the Fund's decision was not based on substantial evidence and that therefore it acted arbitrarily and capriciously.