Opinion ID: 776745
Heading Depth: 2
Heading Rank: 1

Heading: Eligibility for Permanent Benefits

Text: 24 It is well established that federal courts have a narrow role in reviewing the discretionary acts of ERISA plan administrators. See, e.g., Pagan v. NYNEX Pension Plan, 52 F.3d 438, 443 (2d Cir.1995). ERISA empowers federal courts to review the decisions of plan administrators, but provides no authority for a court to render a de novo determination of an employee's eligibility for benefits. See Miller v. United Welfare Fund, 72 F.3d 1066, 1071 (2d Cir.1995) ([N]othing in the legislative history suggests that Congress intended that federal district courts would function as substitute plan administrators....) (internal quotation marks omitted); Pagan, 52 F.3d at 442 (stating that federal courts are not free to substitute [their] judgment for that of the [plan administrator]). Therefore, absent a determination by the plan administrator, federal courts are without jurisdiction to adjudicate whether an employee is eligible for benefits under an ERISA plan. See Jones v. UNUM Life Ins. Co. of Am., 223 F.3d 130, 140-41 (2d Cir.2000). 25 Consistent with this narrow role for federal courts, all of our past decisions presuppose the existence of an eligibility or claim determination on the part of the plan administrator. See id.; Miller, 72 F.3d at 1070-71; Pagan, 52 F.3d at 442; Miles v. N.Y. State Teamsters Conference Pension & Ret. Fund Employee Pension Benefit Plan, 698 F.2d 593, 599 (2d Cir.), cert. denied, 464 U.S. 829, 104 S.Ct. 105, 78 L.Ed.2d 108 (1983). Here, however, Continental made no determination as to whether Peterson was eligible for permanent benefits. Instead, in its April 7, 2000 determination, Continental rejected only Peterson's claim for short-term and occupation-period benefits, but did not address the permanent benefit aspect of the policy. 26 Peterson claims that the District Court's December 8, 1999, remand order directed Continental to render a determination on his eligibility for permanent benefits. However, the court's remand order was at best ambiguous. It referred specifically to the tripartite test used for occupation-period benefits and directed Continental to render a determination on the third element of that test. Thus, Continental was required to determine whether Peterson was employed during the occupation period in an occupation for which he was qualified. However, in its October 23, 2000 order, the court interpreted that directive as applying to the first part of the test for permanent benefits. Although similar in language, the test for permanent benefits differs from the test for occupation-period benefits. The permanent benefits test focuses on whether the employee is permanently unable to engage in any occupation for which the employee is qualified, rather than the claimant's current or regular occupation. Thus, the District Court never directed the administrator to undertake the relevant inquiry for an award of permanent benefits in its remand order. More fundamental, however, was the fact that Continental's decision was made in April 2000, several months before Peterson's occupation period ended. Because Peterson applied for long-term benefits to commence in August 1998, his twenty-four-month occupation period was not scheduled to end until August 2000. Peterson's policy states that permanent benefits will be payable if [a]fter the Monthly Benefit has been payable for Your Occupation Period... You are ... continuously unable to engage in any occupation.... The policy thus explicitly refers to a determination after the occupation period has closed. As Peterson's occupation period was not yet complete, his eligibility for permanent benefits was not an issue ripe for determination by the claim administrator. 27 Under such circumstances, we find that the District Court erred by adjudicating the question of Peterson's eligibility for permanent benefits. Absent a decision by the plan administrator, district courts have no jurisdiction to make an assessment of a beneficiary's eligibility for benefits. The instant case is controlled by our decision in Jones, where we faced a factually similar situation and found that the district court had no jurisdiction over an ERISA benefits question that had not yet ripened into a case or controversy. 223 F.3d at 140-41. In Jones, a plaintiff brought suit seeking long-term disability benefits under an ERISA qualified plan. The district court remanded the case to the plan administrator for a determination on the plaintiff's eligibility for benefits beyond the initial twenty-four-month period, but did not retain jurisdiction over the case while it was remanded. On appeal the plaintiff argued that the court should have retained jurisdiction, allowing her to collect prejudgment interest on amounts owed during the remand period. See id. at 140. We disagreed, holding that because the plan administrator had yet to make a determination in regard to post-twenty-four-month period benefits, there was not yet a case or controversy regarding that issue. See id. at 141. Since the plan had yet to decide whether the plaintiff deserved benefits for the post-twenty-four-month period, the plaintiff had not suffered an actual or threatened injury. See id. Article III of the Constitution provides jurisdiction to district courts only over those disputes in which the plaintiff can demonstrate `some actual or threatened injury as a result of the putatively illegal conduct of the defendant.' Id. (quoting Blum v. Yaretsky, 457 U.S. 991, 999, 102 S.Ct. 2777, 73 L.Ed.2d 534 (1982)). Until then, the issue has not ripened into a dispute capable of conferring jurisdiction on a district court. 28 Following Jones, we find that the District Court exceeded its jurisdiction when it rendered a determination as to Peterson's eligibility for permanent benefits. As of June 2000, when the District Court rendered its decision, Peterson had not yet been denied permanent benefits. In fact, because Peterson's occupation period had yet to expire, the issue was not even ripe for adjudication by the plan administrator, much less by the District Court. By issuing a decision on permanent benefits, the District Court determined a question over which it had no jurisdiction. 29 Accordingly, we vacate the judgment of the District Court insofar as that judgment relates to Peterson's eligibility for permanent benefits. Of course, Peterson is free to file a claim for permanent benefits with Continental. Should he receive an adverse decision after exhausting administrative remedies, he may file a suit in federal court in the normal course. Because of the lack of jurisdiction over the question of permanent benefits, neither this Court nor the District Court may retain jurisdiction over the suit while Peterson pursues his eligibility for permanent benefits with Continental.