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.
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.
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 Group Change in Control Severance Pay Plan, 933 F.2d 1227, 1231 (3d Cir. 1991); McLain v. Metropolitan Life Ins. Co., 820 F. Supp. 169, 174 (D.N.J. 1993) ("Section 1132 of ERISA allows a participant or beneficiary to bring suit to recover benefits under a plan.").
In this case in which plaintiffs are challenging a benefit determination made by the plan administrator, the appropriate standard of the Court's review turns on the language of the Plan itself. In Firestone Tire & Rubber Co. v. Bruch, the Supreme Court, guided by principles of trust law, concluded that for actions grounded in section 1132(a)(1)(B), "a denial of benefits . . . is to be reviewed under a de novo standard unless the benefit plan gives the administrator or fiduciary discretionary authority to determine eligibility for benefits or to construe the terms of the plan." 489 U.S. at 115. If the plan provides the trustee with discretionary authority to determine a participant's eligibility for benefits, the arbitrary and capricious standard applies. Id. at 111 ("'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.'") (quoting Restatement (Second) of Trusts § 187 (1959)); see Hullett v. Towers, Perrin, Forster & Crosby, Inc., 38 F.3d 107, 114 (3d Cir. 1994); Gillis v. Hoechst Celanese Corp., 4 F.3d 1137, 1140-41 (3d Cir. 1993); Abnathya v. Hoffman-LaRoche, Inc., 2 F.3d 40, 45 (3d Cir. 1993); Nazay v. Miller, 949 F.2d 1323, 1335 (3d Cir. 1991); Personnel Pool of Ocean County, Inc. v. Trustees of Locals 472-172, 899 F. Supp. 1362, 1371 (D.N.J. 1995). The trust instrument need not expressly grant discretionary authority; such discretion may be implied through the terms of the plan. See Hullett, 38 F.3d at 114; Luby v. Teamsters Health Welfare & Pension Trust Funds, 944 F.2d 1176, 1181 (3d Cir. 1991).
In this case, defendants argue that the Plan explicitly grants to Prudential, as Claims Fiduciary, full discretion to interpret the Plan, to determine eligibility for benefits, to decide the amount, form and timing of benefits, and to resolve any other matter under the Plan raised by any claimant. (Def. Br. at 11). The language of the Plan is as follows:
Under the Plan the Claims Fiduciary, as Claims and Appeals Administrator, is a fiduciary to whom the Plan grants full discretion, with the advice of counsel, to interpret the Plan, to determine whether a claimant is eligible for benefits, to determine the amount, form and timing of benefits and to resolve any other matter under the Plan which is raised by the claimant or identified by the Claims Administrator or Appeals Administrator. The Claims Fiduciary, as Claims Administrator and Fiduciary, has the exclusive authority to decide all claims under the Plan, and the Claims Fiduciary, as Appeals Administrator and Fiduciary, has exclusive authority to review and resolve any appeal of a denied claim. In the case of an appeal, the decision of the Appeals Administrator shall be final and binding to the full extent permitted under applicable law unless and to the extent that the claimant subsequently proved that a decision of the Appeals Administrator was an abuse of discretion.