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Marcie Van Hoven v. 1199 Seiu Pension & Benefit Funds

February 15, 2012

MARCIE VAN HOVEN, PLAINTIFF,
v.
1199 SEIU PENSION & BENEFIT FUNDS, 1199 MEDICAL DIRECTOR, DEFENDANTS.



OPINION AND ORDER

Before the Court is a Motion for Summary Judgment brought by Defendants 1199SEIU National Benefit Fund (the "Fund") (misnamed "1199 SEIU Pension & Benefit Fund") and 1199 Medical Director (collectively, "Defendants"). Pro Se Plaintiff Marcie Van Hoven ("Plaintiff") filed the Complaint in May 2011 alleging that she was wrongfully denied healthcare benefits for her son. In their Motion for Summary Judgment, Defendants argue that Plaintiff's claim must be dismissed because the services requested by Plaintiff were denied after the Fund determined through its internal appeals process that these services were not covered under the terms of the Plan. For the reasons set forth below, Defendants' Motion is GRANTED.

BACKGROUND

The Fund is an employee welfare benefit plan that is administered in compliance with the provisions of the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. § 1001, et seq., and with Sections 401(a) and 501(a), of the Internal Revenue Code of 1987, as Amended. Def. 56.1 ¶ 3. Under the Plan, the Administrator has discretionary authority to determine eligibility for benefits, to interpret all of the provisions and terms used in the Plan and to decide questions relating to eligibility for benefits. Arzu Aff. Ex. B., Plan VIII.C.

Plaintiff is or was a participant in the Fund. Def. 56.1 ¶ 9. Plaintiff's claim arises under ERISA § 502(a)(1)(B), 29 U.S.C. § 1132(a)(1)(B) because she seeks a benefit from an ERISA plan. Id. at ¶ 5. When a participant objects to the Fund's denial of a benefit, he or she, or the provider as an assignee, is required to file a first-level appeal, and if denied, a second-level appeal to the trustees. Id. at ¶ 10; Arzu Aff. Ex. B, Plan VII.B.

Plaintiff's original provider filed a request for pre-certification for laser vision surgery ("lasik") for Plaintiff's son, which was denied by the Fund because lasik is not a covered service. Id. at ¶ 11. Section VII.D of the Plan states: "What is not covered . . . Charges for services that are not covered by the Benefit Fund, even if the service is medically necessary." Arzu Aff. Ex. B, Plan VII.D. The Fund's Policy #59, regarding Lasik, states: "Lasik surgery will not be covered for any reason, including any diagnosis concerning non-surgical or non-trauma-induced astigmatism and/or anisotropies, because it is intended to correct refractive errors and is considered not medically necessary since more conservative methods (e.g., glasses or contact lenses) can correct the vast majority of most refractive errors." Arzu Aff. ¶ 14.

Plaintiff filed a first-level appeal of the Fund's decision on September 23, 2010, which was also denied. Arzu Aff. Ex. C, Appeal Summary. Plaintiff's second-level appeal to the Board of Trustees was heard on January 25, 2011. Id. Plaintiff again argued that lasik was medically necessary for her son, but the Trustees upheld the denial on the ground that lasik is not a covered benefit. Arzu Aff. Ex. D, Determination Letter.

LEGAL STANDARD

A. Summary Judgment

Summary judgment shall be granted in favor of a movant where "there is no genuine dispute as to any material fact and the movant is entitled to judgment as a matter of law." Fed. R. Civ. P. 56(a). A court must resolve all ambiguities and draw all inferences against the moving party. LaSalle Bank Nat'l Ass'n v. Nomura Asset Capital Corp., 424 F.3d 195, 205 (2d Cir. 2005). The movant bears the burden of establishing the absence of any genuine issue of material fact. Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 256 (1986). A material fact is one that "might affect the outcome of the suit under the governing law," and an issue of fact is genuine "if the evidence is such that a reasonable jury could return a verdict for the nonmoving party." Holtz v. Rockefeller & Co., 258 F.3d 62, 69 (2d Cir. 2001) (internal quotation and citation omitted). "The party against whom summary judgment is sought . . . 'must do more than simply show that there is some metaphysical doubt as to the material facts . . . . The nonmoving party must come forward with specific facts showing that there is a genuine issue for trial.' "

Caldarola v. Calabrese, 298 F.3d 156, 160 (2d Cir. 2002) (quoting Matsushita Elec. Indus. Co. v. Zenith Radio Corp., 475 U.S. 574, 586--87 (1986)).

B. Review of ERISA Benefit Denials

In reviewing a claim for benefits under ERISA, the Supreme Court has held that where the Plan "gives the administrator or fiduciary discretionary authority to determine eligibility for benefits or to construe the terms of the plan," review of benefit denials is deferential. Firestone Tire and Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989). Denials may be overturned as arbitrary and capricious if the decision is " 'without reason, unsupported by substantial evidence or erroneous as a matter of law.' " Kinstler v. First Reliance Standard Life Ins. Co., 181 F.3d 243, 249 (2d Cir. 1999) (quoting Pagan v. NYNEX Pension Plan, 52 F.3d 438, 442 (2d Cir. 1995)).

"A district judge may expand its review of an administrative decision beyond the record in front of the claims administrator upon finding 'good cause' warranting the introduction of additional evidence." Krizek v. Cigna Grp. Ins., 345 F.3d 91, 96 (2d Cir. 2003) (quoting Zervos v. Verizon, N.Y., Inc., 277 F.3d 635, 646 (2d Cir. 2002). Evidence of bias or misconduct could constitute such good cause. DeFelice v. Am. Int'l Life Assurance Co. of N.Y., 112 F.3d 61, 67 (2d Cir. 1997).

Summary judgment is appropriate where the court finds it appropriate to limit its review to the record and finds as a matter of law that a defendant's denial of benefits was not arbitrary and capricious. See, e.g., Pesca v. Board of Trustees, Mason Tenders' District Council Pension Fund, 879 F. Supp. 23, 25 (S.D.N.Y. 1995) (granting summary judgment to ERISA benefit plan trustees because their denial was based on the plain letter of the plan documents); see also Buffalo Anesthesia Assocs., P.C. v. Gang, No. 05 Civ. 0204(s), 2009 WL 1449047 (W.D.N.Y. May 20, 2009) ...


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