Only if the administrator's decision is "wrong, but apparently reasonable," does the court inquire whether the "wrong" decision was tainted by self-interest. Id. at 1566. Decisions that are tainted by self-interest are deemed "arbitrary and capricious." Id. at 1567. Therefore, the threshold question in this court's inquiry is whether Paul Revere's claims administrator correctly applied the policy's relevant provisions when he denied further disability benefits to Rizzo.
C. Application of the Brown Analysis
Upon a careful review of the record in this case, it cannot be said that Paul Revere's decision to terminate Rizzo's benefits was "wrong." On the contrary, the decision to terminate Rizzo's long term disability benefits is consistent with the plain language of the policy and cannot be said to depend upon a mistaken reading of the policy's definition of disability, as plaintiff's counsel suggests.
Dr. Gallick's report of Rizzo's condition, dated October 5, 1994, which gave rise to Paul Revere's denial of continued disability benefits, simply records that Rizzo should be able to return to work "without restrictions" as of October 11, 1994. Paul Revere's Brief, exhibit 5. This can have come as no surprise to Rizzo, who admits that Dr. Gallick told him on the date of his last visit, October 8, 1993, that "it was okay for me to return to work at that time." Affidavit of Paul Rizzo P 7. The record does not reveal why Dr. Gallick was still filling out the Attending Physician's Statement on Rizzo' behalf over a year after Rizzo's last office visit.
It is clear from the terms of the policy that a beneficiary "must be under the care of a doctor while totally disabled." Paul Revere's Brief, exhibit 2, section 2.
Plaintiff's counsel criticizes Paul Revere's reliance upon Dr. Canario's conclusion that Rizzo was capable of doing work "as a truck driver or wherever else he may find employment in the general population," because Dr. Canario did not specifically find that Rizzo was capable of the heavy lifting involved in his job as a delivery person for Hudson Eagle. Rizzo's Brief at 7-8. In short, plaintiff asserts that Rizzo's "own occupation" was that of "a beer truck driver," a job requiring heavy lifting which Rizzo allegedly could no longer do. Rizzo's Brief at 3. Plaintiff contends for too narrow a definition of "total disability" under the policy. Even if plaintiff were limited in his ability to lift heavy objects, a limitation which Dr. Canario's report nowhere indicates and which was rejected by Paul Revere's claims administrator based on the record before him, Rizzo could still be able to fulfill all the "important duties" of a truck driver and delivery person, although perhaps not with Hudson Eagle.
In sum, Paul Revere correctly construed the relevant policy provisions in making its determination to discontinue Rizzo's long term disability benefits. Therefore, this court's review of the administrator's decision must be conducted under the "arbitrary and capricious" standard.
D. Application of the "Arbitrary and Capricious" Standard
The "arbitrary and capricious" standard calls for this court to defer to the claims administrator's decision, unless that decision is "'without reason, unsupported by substantial evidence or erroneous as a matter of law.'" Abnathya, 2 F.3d at 45 (quoting Adamo v. Anchor Hocking Corp., 720 F. Supp. 491, 500 (W.D. Pa. 1989)). The scope of this review is necessarily narrow. Id. Consequently, this court "is not free to substitute its own judgment for that of the defendants in determining eligibility for plan benefits." Id. (quoting Lucash v. Strick Corp., 602 F. Supp. 430, 434 (E.D. Pa. 1984)). The "arbitrary and capricious" standard of review is essentially one and the same as the "abuse of discretion" standard. Id.
Because this court concludes that Paul Revere's decision to terminate Rizzo's LTD benefits is subject to an abuse of discretion standard of review, Abnathya is particularly compelling authority. In Abnathya, the Third Circuit reversed the district court's grant of summary judgment to the plaintiff, and ordered entry of summary judgment in favor of the plan administrator. 2 F.3d at 48. In so doing, the Third Circuit held that it was reasonable for the plan administrator to base his decision to terminate LTD benefits on independent evaluations by two medical doctors chosen by the plan, rather than the testimony of Abnathya's treating physician. Id. at 47. Rizzo attempts to distinguish Abnathya on the basis that the plaintiff underwent a second independent medical examination, prompted in part by her dissatisfaction with the first examination.
Id. at 43.
Rizzo's argument fails to recognize two important points, one factual and one legal. First, in Abnathya, it was the initial independent examination which presented the plan administrator with a difference of opinion with the plaintiff's treating physician. Id. In the present case, it was Rizzo's own treating physician who created the initial difference of opinion, which Dr. Canario was then called upon to resolve. More importantly, Abnathya makes it clear that a fiduciary's decision is not arbitrary and capricious even though it is based upon a single independent medical evaluation, especially when the plan specifically requires the beneficiary to establish his continuing entitlement to benefits. Id. at 47 (citing, with approval, Miller, 925 F.2d at 985).
Rizzo's counsel also protests that Dr. Canario issued only a "two-page summary" of his examination of the plaintiff, noting that Rizzo, like the plaintiff in Abnathya, complained of the "cursory nature" of the examination. Rizzo's Brief at 15; Affidavit of Paul Rizzo at P 14. The Third Circuit brushed aside the identical criticism in Abnathya, noting that the plaintiff had not submitted any evidence that the examination was inadequate or that the two-page report was "below the standards in the profession." Abnathya, 2 F.3d at 47. Aside from Rizzo's own affidavit, there is no evidence in this case that Dr. Canario's examination was flawed in any way.
The record reveals no abuse of discretion in this case. Accordingly, the motion of defendant, Paul Revere Life Insurance Company, for summary judgment on plaintiff's complaint, will be granted. The court will enter an appropriate order.
STEPHEN M. ORLOFSKY
United States District Judge
Dated: May 22, 1996
This matter having come before the Court on May [ILLEGIBLE WORDS], 1996, on the motion of defendant, Paul Revere Life Insurance Company, for summary judgment on plaintiff's complaint, Barry E. Levine, Esq., appearing on behalf of the plaintiff, and Robert Wright, Esq., and Andrew I. Hamelsky, Esq., of Melli & Wright, P.C., appearing on behalf of the defendant; and,
The Court having considered the complaint, the answer, and the briefs, depositions and affidavits filed in support of and in opposition to this motion, for the reasons set forth in this Court's OPINION filed concurrently with this ORDER;
It is on this 22nd day of May, 1996, ORDERED that the motion of defendant, Paul Revere Life Insurance Company, for summary judgment on plaintiff's complaint, is GRANTED.
STEPHEN M. ORLOFSKY
United States District Judge