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NEVINS v. PRUDENTIAL INS. CO. OF AMERICA

April 8, 1997

SUSAN E. NEVINS, Plaintiff,
v.
THE PRUDENTIAL INSURANCE COMPANY OF AMERICA, and BELL ATLANTIC, Defendants.



The opinion of the court was delivered by: SIMANDLE

 SIMANDLE, District Judge:

 Presently before the court is the motion for summary judgment of defendants, The Prudential Insurance Company of America ("Prudential") and Bell Atlantic, which seeks to dismiss plaintiff's complaint. For the reasons stated below, the motion will be denied.

 I. Background

 Plaintiff, Susan Nevins, is an employee of defendant Bell Atlantic, and is a beneficiary of the Bell Atlantic Medical Expense Plan for Active Non-Management Employees and Retired Non-Management Employees ("Plan"). (Compl. at P 1). Defendant Prudential is the Claims Fiduciary under the Plan for certain classes of employees, including plaintiff. (Def. 12G Stmt. at P 5).

 The Plan requires that a Plan beneficiary utilize in-network care providers or else be subject to a lower reimbursement rate for services rendered by out-of-network providers. Plan participants may request an exemption from this requirement based upon the necessity of continuity of care with existing out-of-network providers. Exemptions, when granted, are granted on an annual basis with the exemption reviewed annually and subject to Claims Fiduciary re-evaluation. (Id. at P 8-9).

 Plaintiff received a continuity of care exemption for the years 1992 and 1993, based on her diagnosis of Chronic Pain Syndrome. Plaintiff's requested exemption for 1994 was denied by Prudential in a letter dated December 16, 1993. One of plaintiff's physicians, Dr. Hurowitz, appealed the denial in a letter dated January 4, 1994. Prudential confirmed its denial in a letter to Dr. Hurowitz dated February 22, 1994. In response to a letter from Ms. Nevins, Prudential again denied her request in a letter dated May 10, 1994.

 Following a third letter by Dr. Hurowitz and another appeal by Ms. Nevins, Prudential advised plaintiff by letter dated August 4, 1994, that although her exemption had been reviewed and denied by Prudential's Regional Appeals Committee, she would receive an extension through 1994, but it would no longer be in effect as of January 1, 1995.

 Plaintiff alleges that her request for continuity of care benefits has been wilfully and wrongfully denied for the year 1995. She seeks a declaration that she must be afforded a continuity of care exception under the Plan for 1995 and subsequent years, compensatory damages, counsel fees, interest and costs of suit.

 The Court's jurisdiction arises from the fact that plaintiff seeks a determination of benefits under an employee benefits plan subject to the requirements of the Employees' Retirement Income Security Act ("ERISA"), 29 U.S.C. § 101, et seq.

 II. Discussion

 A. Summary Judgment Standard

 A court may grant summary judgment when the materials of record "show that there is no genuine issue as to any material fact and that the moving party is entitled to judgment as a matter of law." Fed. R. Civ. P. 56(c). In deciding whether there is a disputed issue of material fact the court must view the evidence in favor of the non-moving party by extending any reasonable favorable inference to that party. See Aman v. Cort Furniture Rental Corp., 85 F.3d 1074, 1080-81 (3d Cir. 1996); Kowalski v. L & F Products, 82 F.3d 1283, 1288 (3d Cir. 1996); Meyer v. Riegel Products Corp., 720 F.2d 303, 307 n.2 (3d Cir. 1983), cert. denied, 465 U.S. 1091, 79 L. Ed. 2d 910, 104 S. Ct. 2144 (1984). The threshold inquiry is whether there are "any genuine factual issues that properly can be resolved only by a finder of fact because they may reasonably be resolved in favor of either party." Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 250, 91 L. Ed. 2d 202, 106 S. Ct. 2505 (1986).

 Supreme Court decisions mandate that "when the nonmoving party bears the burden of persuasion at trial, the moving party may meet its burden on summary judgment by showing that the nonmoving party's evidence is insufficient to carry its burden of persuasion at trial." Brewer v. Quaker State Oil Refining Corp., 72 F.3d 326, 329-330 (3d Cir. 1995) (citing Celotex Corp. v. Catrett, 477 U.S. 317, 322-23, 91 L. Ed. 2d 265, 106 S. Ct. 2548 (1987)). However, "the nonmoving party creates a genuine issue of material fact if it provides sufficient evidence to allow a reasonable jury to find for him at trial." Brewer, 72 F.3d at 330 (citing Anderson, 477 U.S. at 248). Once the moving party has carried its burden of establishing the absence of a genuine issue of material fact, "its opponent must do more than simply show that there is some metaphysical doubt as to material facts." Matsushita Elec. Indus. Co. v. Zenith Radio Corp., 475 U.S. 574, 586, 89 L. Ed. 2d 538, 106 S. Ct. 1348 (1986). Thus, if the non-movant's evidence is merely "colorable" or is "not significantly probative," the court may grant summary judgment. Anderson, 477 U.S. at 249-50.

 B. The Court's Review of Prudential's Decision

 In enacting ERISA, Congress sought to "assure the equitable character of employee benefit plans and their financial soundness." Moench v. Robertson, 62 F.3d 553, 560 (3d Cir. 1995) (internal quotations and citations omitted); see Kemmerer v. ICI Americas Inc., 70 F.3d 281, 286 (3d Cir. 1995); Dade v. North American Philips Corp., 68 F.3d 1558, 1562 (3d Cir. 1995); In re Unisys Corp. Retiree Medical Benefit "ERISA" Litigation, 58 F.3d 896, 901 (3d Cir. 1995) ("ERISA is a comprehensive statute enacted to promote the interests of employees and their beneficiaries in employee benefit plans and to protect contractually defined benefits.") (internal quotations omitted). As such, the statute, pursuant to 29 U.S.C. § 1132(a)(1)(B), affords a cause of action to any participant or beneficiary of a plan seeking to recover benefits or enforce rights under the terms of the plan. *fn1" See Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 108, 103 L. Ed. 2d 80, 109 S. Ct. 948 (1989); Taylor v. Continental ...


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