Opinion ID: 197450
Heading Depth: 2
Heading Rank: 2

Heading: Alleged Violations of Arbitrary and Capricious Standard

Text: 132 Having determined that the role of the courts with respect to typical claims under an employee benefits plan is jurisdictionally limited to review, if a plan administrator or fiduciary was given discretion to decide particular claims, we now consider whether Recupero has shown that the Committees created to decide claims of the type at issue in this case acted arbitrarily and capriciously. Recupero argues: 133 Ms. Recupero was seriously injured in an elevator accident at her workplace while she was on-duty and being paid by the company. At the time of her accident she was in the course of her employment and was under the direction and control of her employer. The only reasonable meaning of the Plan language is that Ms. Recupero sustained an accident and not sickness and it was arbitrary and capricious of the Plan to deny her accident disability claim. 134 (Appellant's Br. at 6-7.) Recupero contends that she was: 135 ... en route to obtain coffee in the building lobby at the direction of her supervisor on company time at the time of the accident. She made ... [an] adjustment [from her usual time for a break] at the direction of her supervisor for the sole purpose of furthering, and in direct connection with, the performance of her duties to enable her to establish a conference call with a customer at a time when she would otherwise have been away from her usual work station. 136 (Id. at 13). Thus, she argues, she was on-duty at the time that she sustained her injury, and is entitled to accident benefits. (Id. at 14.) 137 The defendant-appellee counters that [i]t is undisputed that Recupero was injured during break time, after leaving her work station while on an elevator en route to a coffee shop. (Appellees' Br. at 7.) This fact, NET contends, shows that Recupero was not solely and directly engaged in the performance of duties at the time of the injury. (Id.) Thus, the defense argument goes, the Committees did not act arbitrarily and capriciously in determining that Recupero was not entitled to accident benefits. (Id.) 138 As already noted, the district court ruled in favor of NET on this issue. The district court rejected Recupero's argument that, because she was taking her break at the request of her employer, her injuries should entitle her to Accident Disability Benefits. The court stated: 139 Recupero's argument is predicated on the assertion that she was taking her coffee break a half hour early at the request of her supervisor in order to accommodate a job-related phone call which she was expecting. Such a fact is not properly before the court for two reasons. First, the court, when applying the arbitrary and capricious standard of review, may only review the actions of the fiduciary in light of the evidence which was before it at the time it made its decision. It does not appear that the NET Benefits Office, the EBC or the EBCRC had the benefit of considering this fact. (# 20, Exh. 2, Affidavit of Richard Waldron, p 7). Second, this is a mere allegation unsupported by affidavits or as otherwise provided under Fed.R.Civ.P. 56(e) since Recupero offers no evidence to this court to support this contention. 140 (Recupero v. New England Telephone & Telegraph Co., Civil Action No. 94-12266-MLW, Memorandum and Order, Sept. 20, 1996 at 9 n. 5.) 141 The EBC and the EBRC decided that Recupero qualified for Sickness Disability Benefits only. The district court correctly concluded that this decision was not arbitrary and capricious. Three lines of reasoning support this conclusion. 142 First. The court below correctly determined that Recupero had not proffered evidence before the EBC or EBRC of any irregularity in the break from work that she was on when the incident occurred. (Id.) Nothing in the record before the Committees, the record before the district court, or the record before this court suggests otherwise. If Recupero did not proffer, before the Committees, factual support for a contention that the circumstances of the incident brought it within the meaning of an accident because she was taking her break at a specific time, at the behest of her supervisor, in order to allow her to perform her duties at a later time, then the record before the EBC and the EBRC was not sufficient to support a court determination, on judicial review, that the decisions of the Committees were arbitrary and capricious. 143 Second. Despite the difficulties of drawing bright lines of separation and fitting every conceivable circumstance of injury into either the category of accident or the category of sickness, the Committees did not act arbitrarily and capriciously when interpreting on-duty to exclude break time, regardless of the nature of any reason or reasons for the break. A plan may prescribe a definition of on-duty that takes into account the myriad of possible ways in which and times at which an employee may be injured. A plan that does so may require of the out-of-court decisionmakers, in deciding a particular claim, that they make an evaluative determination rather than a rigorously logical application of bright-line rules that leave no choice, even reasoned choice, in arriving at a decision concerning the merit of a particular claim. 144 It is true that in the context of trial of a paradigm tort or contract claim, evaluative issues often go to a jury for decision. See, e.g., Springer v. Seaman, 821 F.2d 871, 876 (1st Cir.1987) (in tort law, not only ordinary fact questions but also evaluative applications of legal standards (such as the legal concept of 'foreseeability') to the facts are properly jury questions), cited with approval in Dedham Water v. Cumberland Farms Dairy, 972 F.2d 453 (1st Cir.1992). 145 In the context of judicial review of out-of-court decisions, however, if employee benefit plan provisions confer discretion on an out-of-court decisionmaker, ordinarily the evaluative determinations of that decisionmaker are judicially reviewed under a deferential standard, as explained in Parts II.B and II.C of this opinion. 146 Section 5(5) of the plan before us in this record is one of the provisions the interpretation of which was challenged in this case. It provides: 147 Relationship of Injury to Employment. Accidental injuries shall be considered as arising out of and in the course of employment only where the injury has resulted solely from accident during and in direct connection with the performance of duties to which the employee is assigned in the service of the Company, or was assigned by the Former Affiliate or Associated or Allied Company from which the employee was reassigned as of January 1, 1984, or which he is directed to perform by proper authority, or in voluntarily protecting the Company's property or interests. There must be a clear and well-established history of the cause and circumstances of injury accidentally inflicted, which must be sufficient to produce the alleged injury, and there must be satisfactory evidence that such injury renders the employee unable to perform his duty in the service of the Company. 148 (Appellees' Br. at 59-60) (emphasis added). In view of the emphasized phrase in this passage quoted from the plan, we cannot say that the district court erred in its interpretation of the plan as supporting NET's position in this appeal. 149 Third. Recupero apparently bases her argument, in part, on an assumption that because she was eligible for worker's compensation, her injury should be treated, as a matter of law, as having occurred on-duty. This assumed premise is erroneous, as a matter of law. Neither ERISA nor any other source of authority declares that the standards of eligibility for workers' compensation benefits and accident disability benefits under an ERISA-regulated plan be the same. See Pagan v. NYNEX Pension Plan, 52 F.3d 438 (2d Cir.1995). Further, the plan provisions in this case do not explicitly prescribe a test for on-duty status that mirrors the test commonly used in worker compensation systems. 150 For these reasons, we conclude that the district court did not err in deciding that the decisions of the EBC and the EBRC were not arbitrary and capricious. 151