When asked about his own opinion of the Insured's care needs as of July, 1989, Dr. Ordene testified that he was not familiar with the distinctions between LPN's and RN's as to the type of care they could provide, but that in his view it would have been advisable that the patient receive his medications and testing every four to six hours from a trained layperson or nursing person, and that someone (not necessarily a nursing professional) monitor him throughout the day and night in case of fainting or falling. Thus, stated Dr. Ordene, as of that time he would not have hesitated to release the insured to a suitable nursing home, if the family had expressed interest in that type of care, which they did not.
Dr. Ordene's records further showed that the insured was hospitalized later in August 1989, and he was also hospitalized from September 25 to October 16, 1989, but that Dr. Ordene was not one of the treating physicians on those occasions.
The Insured died on November 25, 1989 (per death certificate, P-17), and there is no allegation against the Fund regarding the cause or timing of his death.
CONCLUSIONS OF LAW
This Court has jurisdiction over the subject matter of this action pursuant to 29 U.S.C. § 1132(a)(1)(B) and 28 U.S.C. § 1331. Venue is proper in this district pursuant to 28 U.S.C. § 1391 (b).
The issue which has been tried to this Court, sitting without a jury, as contained in the Sixth Count of one Amended Complaint, is whether the plaintiff, as assignee of one insured, is entitled to recover from the Fund payment for round-the-clock registered nurse services rendered by plaintiff to the insured during the stated period, totaling $ 15,632.51. The facts have been developed upon the full record at trial, and he legal conclusions are as follows.
The Supreme Court has determined that in actions such as the present case, involving claims for benefits arising under ERISA plans pursuant to 29 U.S.C. § 1132(a)(1)(B),
the appropriate standard of judicial review of the trustee's decision depends upon the language of the trust. In Firestone Tire and Rubber Co. v. Bruch, 489 U.S. 101, 103 L. Ed. 2d 80, 109 S. Ct. 948 (1989), the Supreme Court established the rule applicable in § 1132(a)(1)(B) actions, that "where discretion is conferred upon the trustee with respect to the exercise of a power, its exercise is not subject to control by the court except to prevent an abuse by the trustee of his discretion." Id. (quoting Restatement (Second) of Trusts § 187 (1959)). However, where the trust agreement does not give one trustee power to construe uncertain provisions of the plan, or to make eligibility determinations, the trustee is not entitled to deference and courts exercise de novo review. Id. at 111-12. The "abuse of discretion" standard referred to in Firestone is also commonly referred to as the deferential or "arbitrary and capricious" standard, see Abnathya v. Hoffman-LaRoche, Inc., 2 F.3d 40, 45 n.4 (3d Cir. 1993) ("the 'arbitrary and capricious' standard is essentially the same as the 'abuse of discretion' standard.") Under that standard, "the district court may overturn a decision of the Plan administrator only if it is without reason, unsupported by substantial evidence or erroneous as a matter of law.' . . . This scope of review is narrow, and 'the court is not free to substitute its own judgment for that of the defendants in determining eligibility for plan benefits.'" Id. at 45 (citations omitted).
The Agreement and Declaration of Trust governing tie Fund in this case states that "subject to the stated purposes of the Fund and the provisions of this Agreement, the Trustees shall have full and exclusive authority to determine all questions of coverage and eligibility, . . . . They shall have full power to construe the provisions of this Agreement, the terms used herein and the by-laws and regulations issued thereunder. Any such determination and any such construction adopted by the Trustees in good faith shall be binding upon all of the parties hereto and the Beneficiaries hereof." The stated purpose of the Fund is that of providing such benefits as . . . are . . . authorized, or permitted by law for Participants and their Beneficiaries and in accordance with the provisions herein set forth and the Welfare Plan."
This same Fund and Plan were reviewed by the Court of Appeals for the Third Circuit in Myszka v. Aon Corporation, Heavy and General Laborer Local Unions 472 and 172, et al., 39 F.3d 1170, (3d Cir. 1994), another case involving a claim for health care benefits, wherein the Court concluded that the Trustees' determination was subject to review under the arbitrary and capricious standard. Following that precedent, as the district court must, and also because the quoted language of the Trust Agreement clearly confers upon the Trustees broad discretion and authority to construe the terms of the Plan, this Court similarly must review the Fund's decision in this case under the deferential standard.
The arbitrary and capricious standard requires the reviewing court to disturb an ERISA trustee's medical benefits interpretation only if the trustee's reading of the plan documents was unreasonable. See Firestone, 489 U.S. at 111; Moench v. Robertson, 62 F.3d 553, 566 (3d Cir. 1995 ).
The Court of Appeals for the Third Circuit has referred with approval to a series of helpful factors to consider in determining whether an interpretation of a plan is reasonable; see Moench at 566-67. Those factors are:
(1) whether the interpretation is consistent with the goals of the Plan;