The opinion of the court was delivered by: FRANK MAAS, Magistrate Judge
This action under the Employee Retirement Income Security Act
of 1974 ("ERISA"), 29 U.S.C. § 1001, et seq., is brought by
plaintiff Michael Sammarco ("Sammarco"), a participant in the
Local 812 Health Fund ("Fund"), to secure health benefits that
the defendant Trustees ("Trustees") declined to provide following
an accident on January 10, 2002 ("Accident"), in which he was
seriously injured. The parties previously consented to my
exercise of jurisdiction over this matter pursuant to
28 U.S.C. § 636(c). (See Docket No. 2). They now have cross-moved for
summary judgment pursuant to Rule 56 of the Federal Rules of
Civil Procedure. For the reasons detailed below, the Trustees'
motion is granted, Sammarco's motion is denied, and the complaint
is dismissed. I. Factual Background
The following facts are undisputed. In 2002, Sammarco was
employed by his own corporation, which was an independent Pepsi
Cola distributor. (See Sammarco Aff. ¶¶ 3, 7). As such, he was
a member of the Local 812 health plan ("Plan"), which is an ERISA
benefit plan. (See id. ¶ 7; Warner Aff. Ex. A at 53).
Although Sammarco had the option of also securing Workers'
Compensation coverage, his accountant advised him that New York
law permits an owner employer not to participate in that
coverage. (Sammarco Aff. ¶ 7). He therefore did not purchase any
Workers' Compensation coverage for himself. (See id. ¶ 10).
The Fund's Summary Plan Description which was in effect on the
date of the Accident and when Sammarco submitted his claims was
the version revised and restated as of June 1, 1996 ("1996 SPD").
(See id. ¶ 7; Warner Aff. ¶ 8, Ex. A). The 1996 SPD contained
nearly forty coverage exclusions. (See Warner Aff. Ex. A at
22-25). The third of these exclusions ("Exclusion 3") provided
that the Fund would not pay
[c]harges arising out of or in the course of any
occupation for wage or profit, or for which the
covered person is entitled to benefits under any
Worker's Compensation or Occupations Disease Law, or
any such similar law[.]
(Id. at 22).
Following the Accident and Sammarco's submission of his claims,
the Fund revised its Summary Plan Description to clarify the
Plan's benefits and exclusions effective January 1, 2003 ("2003
SPD"). (See id. Ex. G at 1-2). The 2003 SPD contained a third exclusion substantially similar to Exclusion 3.
(See id. at 24). However, the 2003 SPD further described the
relationship between the Fund's health benefits and Workers'
Compensation coverage as follows:
If you incur a work related injury or illness, any
claims related to that injury or illness must be
submitted through your employer for Workers'
Compensation coverage. No benefits are payable by the
Fund for claims related directly or indirectly to a
work-related injury or illness unless the claim is
denied by Workers' Compensation. Every participant
must be covered by Workers' Compensation regardless
of whether the law permits a voluntary exemption.
. . .
Where Workers' Compensation would cover your injury
or illness and you do not have Workers' Compensation
coverage, the Fund will consider your claim as if you
did have it and determine benefits accordingly.
(Id. at 29-30) (emphasis added). The 1996 SPD did not contain
any comparable explanatory language.
On the date of the Accident, Sammarco returned to the Pepsi
Cola plant from his delivery route at approximately 5:30 p.m.
after a twelve-hour shift. (Sammarco Aff. ¶ 3). As was his
custom, Sammarco parked his truck at the plant so that Pepsi Cola
employees could reload it overnight. (Id.). Sammarco also
completed certain necessary paperwork. (Id.). By about 6:15
p.m., his work for the day was done. (Id.).
At the time, Sammarco was in the process of planning a
confirmation party for his son. (Id. ¶ 5). Accordingly,
Sammarco went into a "back area" of the plant in an effort to locate Jerry Troyanos, a Pepsi Cola employee who "had a
band" (Id.). Although Troyanos was on vacation, Sammarco
contacted him by telephone and agreed to meet at the plant at 7
p.m. (Id.; Troyanos Aff. ¶¶ 4-5).
At approximately 7:15 p.m., while he was in the back area of
the plant to meet with Troyano to discuss his need for a band,
Sammarco slipped on an oil slick on the floor near several
leaking "hi-los." (Sammarco Aff. ¶ 6; Troyanos Aff. ¶ 5).
Sammarco suffered a concussion, a right shoulder dislocation, and
a collapsed lung, among other injuries, and he underwent surgery.
(Sammarco Aff. ¶ 8).
Sammarco and his health care providers submitted bills to the
Fund for his medical care, but the Plan Administrator
("Administrator") denied payment.*fn1 (Id. ¶ 9). At the
time, Sammarco's understanding was that the denial was based upon
Exclusion 3, even though he did not have Workers' Compensation
coverage. (Id. ¶ 10). He later learned from his attorneys that
the Fund was rejecting his claims because he "could have obtained
[W]orker[s'] [C]ompensation had [he] wanted to." (Id.).
On May 17, 2002, Sammarco's counsel wrote to the Administrator
in an effort to reverse the Administrator's prior decision. In
his letter, counsel stated that Sammarco
was injured while at the Pepsi Cola plant but he is
not an employee of Pepsi Cola. He therefore has no
[W]orkers [C]ompensation benefits available in connection with
the injuries he suffered in his [Accident.]
(Saunders Decl. Ex. 1). Counsel also threatened to file a lawsuit
unless the Administrator corrected its error "immediately."
On June 4, 2002, counsel again wrote to the Administrator.
(See id. Ex. 2). This second letter noted the lack of any
response to the May 17th letter. (Id.). Counsel also observed
that he previously had advised the Administrator that Sammarco
"was an independent trucker who happened to be injured in the
Pepsi Cola plant while picking up a load of goods for his
distribution." (Id.) (emphasis added).
Finally, on July 31, 2002, counsel wrote to Pat Paolucci, an
officer of the Administrator. (See id. Ex. 3). In that
letter, counsel complained that Sammarco's claim had been denied
in the mistaken belief that "he should receive [W]orkers'
[C]ompensation." (Id.). Counsel indicated that one of his