The opinion of the court was delivered by: Dennis M. Cavanaugh, U.S.D.J.
This matter comes before the Court upon motion for summary judgment by Defendant Northern New Jersey Teamsters Benefit Plan ("NNJ Plan") to dismiss Plaintiff Jamie Londono's ("Londono") claim for benefits. No oral argument was held pursuant to Federal Rule of Civil Procedure 78. For the following reasons, NNJ Plan's motion for summary judgment is granted.
NNJ Plan is a multi-employer "employee benefit plan" established in collective bargaining between Local 11, I.B.T. and certain other participating unions and employers. (Statement of Undisputed Material Facts ("Statement of Facts") at ¶ 1; Declaration of Robert Eaton ("Eaton Decl.") at ¶ 2). NNJ Plan is maintained pursuant to an Amended and Restated Agreement and Declaration of Trust ("Trust Agreement"). (Exhibit ("Ex.") 1, attached to Eaton Decl.). The Trust Agreement grants NNJ Plan's trustees "full authority to determine eligibility requirements for benefits." (Eaton Decl. at ¶ 6; Ex. 1 at 16). The Plan D summary plan description also states that the trustees have broad authority to interpret the individual plans' terms and the Trust Agreement. (Eaton Decl. at 7; see also Ex. 2, attached to Eaton Decl., at 1- 2). NNJ Plan provides hospitalization, medical, and other benefits to employees covered by collective bargaining agreements. (Statement of Facts at ¶ 4; Eaton Decl. at ¶ 4). These collective bargaining agreements require that contributions are made on the employee's behalf to NNJ Plan. (Id.). NNJ Plan offers several benefit plan levels. (Id.). The plan participant's employer's collective bargaining agreement determines the participant's benefit plan level. (Id.). A plan participant is entitled to only those benefits listed in his or her plan. (Statement of Facts at ¶ 6; Eaton Decl. at ¶ 7).
Londono was eligible for coverage under NNJ Plan's "Plan D" level of benefits. (Statement of Facts at ¶ 5; Eaton Decl. at ¶ 5). The Plan D summary plan description sets forth procedures for submitting claims for benefits and appealing denied claims. (Eaton Decl. at ¶ 8; Ex. 2 at 87-100). Under Plan D's appeals procedure, claimants must submit appeals in writing within 180 days of receiving notice of NNJ Plan's decision on a claim. (Eaton Decl. at ¶ 8; Ex. 2 at 95). Written appeals must contain the following information: (1) name(s) and address(es) of patient and participant; (2) participant's Horizon identification number; (3) date(s) of service; (4) claim number; (5) provider's name and address; and (6) why the participant believes NNJ Plan's decision was incorrect. (Ex. 2 at 95-96). If NNJ Plan's trustees return an unfavorable decision on appeal and the participant has fully exhausted the appeals process, the participant may file a lawsuit within twelve months of the final notice denying benefits. (Ex. 2 at 99).
In his complaint, Londono does not list the dates when he received medical services and the medical providers that rendered the services. (See Complaint). Londono only mentions that NNJ Plan suspended payments for an MRI and a back specialist (Id.). NNJ Plan does not have any record of any appeal filed by Londono with respect to any claims for benefits prior to the commencement of this action. (Eaton Decl. at ¶ 9).
II. Standard of Review: Summary Judgment
Under the Federal Rules of Civil Procedure, summary judgment is only appropriate when there is no genuine issue as to any material fact and the moving party is entitled to judgment as a matter of law. See Fed. R. Civ. P. 56. Rule 56(e) requires that the non-moving party set forth specific facts showing a genuine issue for trial when a motion for summary judgment is made. Id.; see Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 250 (1986). Only disputes over facts that might affect the outcome of the lawsuit will preclude the entry of summary judgment. Anderson, 477 U.S. at 247-248.
The burden is on the moving party to demonstrate the absence of a genuine issue of material fact. Celotex Corp. v. Catrett, 477 U.S. 317, 323 (1986); see Adickes v. S.J. Kress & Co., 398 U.S. 144, 157 (1970). An issue is "genuine" if a reasonable jury could possibly hold in favor of the non-moving party with regard to that particular issue. Anderson, 477 U.S. at 247-248. In deciding a motion for summary judgment, a court must view the facts in the light most favorable to the non-moving party and must resolve any reasonable doubt as to the existence of a genuine issue of material fact against the moving party. Matsushita Elec. Indus. Co. v. Zenith Radio Corp., 475 U.S. 574, 587 (1986).
In this action, NNJ Plan asserts that Londono's claims must be dismissed because: (1) Londono's state law claims are preempted by ERISA; and (2) Londono failed to exhaust the administrative remedies outlined in Plan D's summary plan description. For the following reasons, NNJ Plan's motion for summary judgment is granted.
A. Londono's State Law Claim is Dismissed Because it is Preempted by ERISA
Courts generally determine whether a state action is preempted by a federal statute by examining Congressional intent. Allis-Chalmers Corp. v. Lueck, 471 U.S. 202, 208 (1985); Malone v. White Motor Corp., 435 U.S. 497, 504 (1978). The United States Supreme Court determined that one of ERISA's main objectives was to eliminate state regulation of employee benefit plans. See Ingersoll-Rand Co. v. McClendon, 498 U.S. 133, 138 (1990); Alessi v. Raybestos-Manhattan, Inc., 451 U.S. 504, 523 (1981) (stating that ERISA "establish[ed] pension plan regulation as exclusively a federal concern"). ERISA provides:
Except as provided in subsection (b) of this section, the provisions of this subchapter and subchapter III of this chapter shall supersede any and all State laws insofar as they may now or hereafter relate to any employee benefit plan described in section 1003(a) of this title and not exempt under section 1003(b) of this title. 29 U.S.C. § 1144(a). It has been stated that ERISA's preemption provisions were "deliberately expansive." Pilot Life Ins. Co. v. Dedeaux, 481 U.S. 41, 46 (1987); see also Keystone Chapter, Associated ...