Searching over 5,500,000 cases.


searching
Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.

RIZZO v. PAUL REVERE INS. GROUP

May 22, 1996

PAUL RIZZO, Plaintiff,
v.
PAUL REVERE INSURANCE GROUP, Defendant.



The opinion of the court was delivered by: ORLOFSKY

 ORLOFSKY, District Judge:

 Plaintiff, Paul Rizzo, ("Rizzo"), filed this action against Paul Revere Life Insurance Company ("Paul Revere") under the civil enforcement provision, Section 502(a)(1)(B), of the Employee Retirement Income Security Act ("ERISA"), *fn1" seeking review of Paul Revere's decision to discontinue his long term disability ("LTD") insurance benefits. Jurisdiction is conferred upon this court by 28 U.S.C. § 1331. Defendant, Paul Revere, has filed a motion for summary judgment, pursuant to Fed. R. Civ. P. 56(b). Paul Revere contends that its decision to terminate Rizzo's LTD benefits is subject to review by this court only under an "arbitrary and capricious" standard of review. In opposition, Rizzo argues that this court should review de novo the decision to terminate his benefits.

 The question presented requires this court to determine what standard of review should be applied to a decision by an ERISA fiduciary who, as "claims administrator," is vested with "full, final and binding" authority to make conclusive determinations of an individual employee's eligibility for long term disability benefits, when that fiduciary is also the insurer which underwrites the policy of long term disability insurance upon which the ERISA plan is based. For the reasons set forth below, this court concludes that, in the circumstances of this case, the decision of Paul Revere, acting in its capacity as "claims administrator" under the plan, should be reviewed under the more deferential "arbitrary and capricious" standard of review.

 I. Facts and Procedural History

 Plaintiff, Paul Rizzo, is a thirty-five year old man who was last employed as a commercial truck driver and delivery person for Hudson Eagle Distributing Company ("Hudson Eagle"), a beer distributor. Rizzo's duties with Hudson Eagle often required him to lift cases and kegs of beer. On or about September 1, 1993, while in the course of his employment, Rizzo suffered a back injury. He sought medical treatment from Dr. Harold Fischer. Shortly thereafter, Dr. Fischer referred Rizzo to Dr. Gregory Gallick, who treated him briefly. Plaintiff's Brief in Opposition to Defendant's Notice of Motion for Summary Judgment ("Rizzo's Brief") at 4.

 Defendant, Paul Revere, issued a group long term income disability insurance policy to Hudson Eagle on August 15, 1993, in which Rizzo was enrolled. Defendant's 12G Statement P 2. The group policy, which bears the number G-44249, is an employee benefit plan within the meaning of ERISA, *fn2" because it was maintained by an employer for its employees. The employees, however, were responsible for 100% of the premiums of the group insurance, presumably through payroll deductions. Brief in Support of Defendant, Paul Revere's Motion for Summary Judgment ("Paul Revere's Brief"), exhibit 1, at 2. Hudson Eagle was responsible for making monthly premium payments to Paul Revere. Id. exhibit 2, at 1.

 The policy provides LTD benefits to those who become "totally disabled," or are "residually disabled" as a result of an accident or disease affecting them while they work for Hudson Eagle. The LTD policy in which Rizzo was enrolled provides the following definitions of a disability for which coverage applies:

 
DISABLED OR DISABILITY These unqualified terms may mean either total disability or residual disability. This Policy provides benefits for:
 
1. total disability from any occupation;
 
2. total disability from the employee's own occupation; and
 
3. residual disability
 
. . . .
 
Totally disabled from the employee's own occupation or total disability from the employee's own occupation means:
 
1. because of injury or sickness, the employee cannot perform the important duties of his own occupation; and
 
2. the employee is under the regular care of a doctor; and
 
3. the employee does not work at all.

 Rizzo's Brief, exhibit A, section 1.

 Rizzo does not dispute that the Paul Revere policy, number G-44249, is governed by ERISA. Rizzo's Brief at 9. Furthermore, Paul Revere included in the policy application, which was signed by Hudson Eagle's President, Carlos A. Rivera, a Notice ...


Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.