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VAN WUYCKHUYSE, v. METROPOLITAN LIFE INS. CO.

February 9, 2001

ROBERT VAN WUYCKHUYSE, PLAINTIFF,
V.
METROPOLITAN LIFE INSURANCE COMPANY AND KODAK ACCIDENTAL DEATH INSURANCE PLAN, DEFENDANTS.



The opinion of the court was delivered by: Siragusa, District Judge.

Decision and Order

I. Introduction

The Plaintiff filed a complaint with the Court on June 21, 2000, alleging that the Defendants improperly denied benefits to him under an accidental dismemberment policy. Both parties agree that the plan involved here falls under the provisions of the Employee Retirement Income Security Act of 1974 ("ERISA"). This case is before the Court on the Defendants' motion for summary judgment and the Plaintiff's cross-motion for summary judgment. Because the Court finds that the Plan Administrator's decision was not arbitrary and capricious, the Court denies the Plaintiff's motion for summary judgment and grants the Defendants' motion for summary judgment, dismissing the case.

II. Background

The plan at issue here is the January 1, 1997, Kodak Accidental Death Insurance Plan ("Plan"). A copy of that plan is attached to the affirmation of Pamela R. Cromp as Exhibit A. Under Article nine of the Plan, a beneficiary who loses his thumb is entitled to dismemberment benefits of twenty-five percent of the employee's choice of coverage. Since the Plaintiff chose coverage of $500,000, he would be entitled to $125,000 if he met the Plan's requirements for loss of thumb.

On November 20, 1997, the Plaintiff was severely injured in a hunting accident when a shotgun slug or bullet hit his right thumb. According to his doctor, Jeffrey A. Jones, M.D., the Plaintiff lost "3/4 of his thumb metacarpal, loss of the bone attaching the thumb to the rest of the hand (trapezium), as well as skin and muscle damage and complete transaction of the median nerve all from a single bullet wound." Letter from Jeffrey A. Jones, M.D. to Ian Mackler, Esq. (Nov. 23, 1998) at 1 (contained in Cromp affirmation, Exhibit F).

The Plan defines Loss of Thumb at section 2.17, which states, in pertinent part: "`Loss of Thumb' means that a Participant's thumb is severed at or above knuckle joint nearest the hand." Section 13.4, Governing Law, states that, "[t]his document shall be construed and governed in accordance with the laws of New York State, except as such laws are preempted by applicable federal law."

Article 11 of the Plan gives the Plan Administrator "the exclusive right: to interpret the Plan; to determine eligibility for Coverage; to determine eligibility for Benefits; to construe any ambiguous provision of the Plan; to correct any default; to supply any omission; to reconcile any inconsistency; and to decide any and all questions arising in the administration; interpretation; and application of the Plan." Plan section 11.1(b). This article further provides:

The Plan Administrator shall have full discretionary authority in all matters related to the discharge of his responsibilities and exercise of his authority under the Plan including, without limitation, his construction of the terms of the plan and his determination of eligibility for Coverage and Benefits. It is the intent of the Plan that the decisions of the Plan Administrator and his action with respect to the Plan shall be conclusive and binding upon all persons having or claiming to have any right or interest in or under the Plan and that no such decision or action shall be modified upon judicial review unless such decision or action is proven to be arbitrary or capricious.

Plan section 11.1(c).

On or about May 13, 1998, the Plaintiff applied for accidental dismemberment benefits in the amount of $125,000. The application was made to the Metropolitan Life Insurance Company. See Cromp affirmation Exhibit B. Metropolitan was the Claims Administrator under the Plan. See Plan section 13.1. On November 11, 1998, Metropolitan denied the Plaintiffs claim finding that while the Plaintiff had lost, "approximately 75% of [his] thumb metacarpal (the bone between the thumb and the hand), [his] thumb was not severed."

Pursuant to section 11.4 of the Plan, the Plaintiff appealed this decision to the Plan Administrator, the Director, Compensation, Benefits and Staffing, U.S. & G., Human Resources, Eastman Kodak Co. See Ian Mackler, Esq. letter to Susan Izzo (Nov. 18, 1998), Cromp affirmation Exhibit D. On June 16, 1999, the Plan Administrator, Pamela R. Cromp, affirmed the decision of the Claims Administrator. See Pamela R. Cromp letter to Ian Mackler, Esq. (June 16, 1999), Cromp affirmation Exhibit E. Ms. Cromp wrote:

The facts demonstrate that Mr. Van Wuyckhuyse's injury did not involve a severing of the thumb at or above the knuckle joint and, therefore, did not constitute a "Loss of Thumb" within the meaning of the plan. Although Dr. Jones noted that Mr. Van Wuyckhuyse's injury was "similar to" a thumb severance and replantation, he also acknowledges in his 11/23/98 correspondence that "the thumb blood vessels ...

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