JOHN G. KOELTL, District Judge.
Plaintiff Abdo Obaid commenced this action under the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. § 1132(a)(1)(B). He alleges that defendants Building Service 32BJ Pension Fund (the "Pension Fund") and the Board of Trustees of Building Service 32BJ Pension Fund (the "Trustees") wrongfully denied him disability benefits. The parties agreed to try this action as a non-jury trial based on a stipulated Administrative Record ("AR") and their trial briefs. Endorsed Letter, May 28, 2013, ECF No. 13; Endorsed Letter, Mar. 26, 2013, ECF No. 7. Based on that procedure, and pursuant to Rule 52(a) of the Federal Rules of Civil Procedure, the Court makes the following findings of fact and conclusions of law.
1. From 1975 to 2009, Obaid worked as a custodian in office buildings in New York City. AR 356. He was a member of the Service Employees International Union, Local 32BJ (or its predecessor in interest) during that time and was a participant in the Pension Fund.
2. The Pension Fund is a multi-employer benefit fund established pursuant to the Taft-Hartley Act, 29 U.S.C. § 186(c)(5). AR 5-6. The Fund is jointly administered by an equal number of management and union trustees and is governed by an Agreement and Declaration of Trust. AR 12.
3. The Pension Plan provides that to be eligible for a permanent disability pension, a participant must be "permanently and totality disabled," must have at least 120 months of service credits, and must have become disabled while working in covered employment. AR 66.
4. Under the Pension Plan, a participant is "permanently and totality disabled" if he is found "totally and permanently unable, as a result of bodily injury or disease, to engage in any further employment or gainful pursuit." AR 66;
5. At the time that Obaid submitted his application, the Pension Fund had delegated to MetLife the authority to make clinical determinations related to disability pension applications and appeals. AR 256, 259B-60.
6. In support of his disability pension application, Obaid submitted a letter from his primary physician, Dr. Iraj Akhavan. The letter identified a number of conditions that Obaid suffered from, including hip joint arthritis and cartilage loss. Dr. Akhavan considered Obaid "totally disable[d] and unable to do any type of job related activities." AR 277. Obaid also submitted MRI results, blood test results, x-rays, prescriptions, and notes from Dr. Akhavan. AR 278-98.
7. In a letter dated July 12, 2010, MetLife informed Obaid that his application for disability pension benefits had been denied. In relevant part, the denial letter stated:
8. The denial letter does not identify what "sedentary work" that Obaid was qualified to perform.
9. In a letter also dated July 12, 2010, MetLife approved Obaid's "claim for long Term Disability (LTD) Benefits from the Building Service 32BJ Health Fund." AR 309. This benefit is provided to covered employees who become "totally disabled while working in covered employment." Def's. Opening Br. App. A.
10. Obaid timely appealed by a letter dated July 20, 2010. AR 374.
11. MetLife submitted Obaid's appeal to Dr. Robert Broghammer, who then wrote a "Peer Review Report." AR 405. The Peer Review Report concluded that medical evidence showed that Obaid had "functional limitations" but that he was capable of "working an eight hour day." AR 407. However, the Report does not identify what type of sedentary work Obaid is qualified to do. Dr. Broghammer also noted that Obaid's "arthritis is a permanent condition. If it advances enough, the claimant would be a candidate for a total hip arthroplasty which itself would also likely result in some permanent restrictions."
12. A copy of the Peer Review Report was sent to Dr. Akhavan for comment. In a letter dated September 20, 2010, Dr. Akhavan responded by noting that Dr. Broghammer's report assumed that Obaid performed "desk work[]." Dr. Akhavan explained that Obaid was a custodian, which is more physically demanding than sedentary work. AR 317.
13. On September 21, 2010, Dr. Broghammer issued an addendum to the Peer Review Report. The addendum stated that "[t]he claimant is capable of frequent (up to 2/3 of the day) standing/walking in an 8 hour day. There is no support for restrictions on lifting and carrying." AR 428.
14. MetLife denied the appeal in a letter dated September 28, 2010. In relevant part, the letter stated:
15. The appeal denial letter does not identify what "other occupations" that Obaid could perform.
16. Obaid filed a complaint in this Court on January 1, 2013, pursuant to § 1132(a)(1)(B). The complaint requests all disability pension benefits wrongfully withheld from Obaid from April 2010 to the date of judgment, minus all long term disability benefits and early retirement pension benefits actually paid to Obaid.
17. The parties agreed to try this action as a non-jury trial based on a stipulated administrative record and their trial briefs. Endorsed Letter, May 28, 2013, ECF No. 13; Endorsed Letter, Mar. 26, 2013, ECF No. 7.
1. To the extent any of the foregoing findings of fact is a conclusion of law, it is hereby adopted as a conclusion of law, and vice versa.
2. The Court has jurisdiction pursuant to 28 U.S.C. § 1331 and 29 U.S.C. § 1132(e)(1) and (f).
3. Under ERISA, a plan participant may sue "to recover benefits due to him under the terms of his plan, to enforce his rights under the terms of the plan, or to clarify his rights to future benefits under the terms of the plan." 29 U.S.C. § 1132(a)(1)(B).
4. The parties agree that the Pension Plan is an "employee welfare benefit plan" subject to ERISA.
5. Obaid filed the complaint within the applicable six-year statute of limitations.
6. The Court reviews the denial of benefits de novo "unless the benefit plan gives the administrator or fiduciary discretionary authority to determine eligibility for benefits."
7. The Pension Plan affords the "Trustees or their authorized delegate(s) ... sole and absolute discretion" to determine whether a participant is totally and permanently disabled. AR 66;
8. However, when a plan administrator has a conflict of interest, that conflict is a factor that should be weighed "as a factor by the reviewing court in determining whether the plan administrator abused its discretion in denying benefits."
9. The defendants note that the Trustees delegated to MetLife the authority to make disability benefit determinations, and that the Pension Fund pays MetLife a flat fee for each benefits application, regardless of whether MetLife awards or denies benefits. AR 259B-60. This, according to the defendants, obviated any potential conflict of interest. Obaid agrees that the Trustees have the power to delegate the authority to adjudicate disability benefits applications. However, Obaid insists that there is no evidence that the Trustees properly delegated this authority to MetLife.
10. The Court need not resolve this argument. Under the standard of review requested by the defendants—arbitrary and capricious review—the denial of disability pension benefits was erroneous as a matter of law.
11. Section 4.08 of the Pension Plan provides that a participant is entitled to a disability pension if "he is permanently and totally disabled (as defined in Section 4.10)," "he has at least 120 months of Service Credits," and "he became permanently and totally disabled while working in Covered Employment." AR 66. The defendants do not dispute that Obaid has at least 120 months of service credits and became disabled while working in covered employment.
12. But the defendants do dispute that Obaid is "permanently and totally disabled (as defined in Section 4.10)." Section 4.10 of the Pension Plan provides that a participant is totally and permanently disabled "if, on the basis of medical evidence satisfactory to the Trustees, he is found to have become, while working in Covered Employment, totally and permanently unable, as a result of bodily injury or disease, to engage in any further employment or gainful pursuit." AR 66. The Summary Plan Description ("SPD") similarly provides that "[t]otal and permanent disability is the permanent inability to work in any capacity, as determined by the Trustees or persons they designate. You will not satisfy this definition of total and permanent disability just because you are unable to continue in your usual occupation; you must be forever unable to perform any gainful employment to meet this Plan requirement." AR 167.
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14. Here, neither the initial application denial letter nor the appeal denial letter considered whether Obaid is vocationally capable of earning a reasonably substantial income. The denial letter states that Obaid "may not be able to return to [his] job as [c]ustodian, but [he] may have sedentary work capacity in the future." AR 313. And the appeal letter states that "[a]lthough you may be disabled from performing your custodial position, given your restrictions and limitations as noted above, you are able to perform other occupations." AR 320-21. At no point does either letter identify any "sedentary" employment for which Obaid was qualified or that actually existed.
16. The defendants now agree that Obaid is totally disabled but argue that he failed to prove that his disability is permanent. In their briefs, the defendants insist that had Obain elected to have hip surgery, he could have continued working.
17. There is no evidence in the record to support this argument. The claim denial letter states that "you may require hip surgery in the future. As a result, you will have limitations and restrictions that would preclude your abilities [sic] to return to work as a [c]ustodian." AR 313. And the appeal denial letter simply states that Obaid's injuries would not prevent him from "performing any occupation. Although you may be disabled from performing your custodial position[,] ... you are able to perform other occupations." AR 320-21. Indeed the Peer Review Report, upon which the appeal denial letter relied, states that "[t]he claimant's hip arthritis is a permanent condition. If it advances enough, the claimant would be a candidate for total hip arthoplasty which itself would also likely result in permanent conditions. The claimant's hip arthritis is a permanent condition. It will not get better with time and will likely progress." AR 407 (emphasis added). There is no basis for the defendants' speculation that if only the plaintiff has a hip replacement, then all will be better. And that was not the basis on which the plaintiff was denied benefits.
18. If a plan administrator's decision was arbitrary and capricious, courts often remand with instructions to consider additional evidence.
The plaintiff is entitled to a judgment equal to the disability pension benefits withheld from the date of entitlement to the date of judgment, minus all long term disability benefits and early retirement pension benefits actually paid to Obaid. The plaintiff is also entitled to disability pension benefits going forward.
However, neither party has briefed (a) the precise dollar amount of disability benefits that was improperly withheld from Obaid, (b) whether Obaid is entitled to attorney's fees and costs, (c) the proper amount, if any, of the fees and costs, (d) whether Obaid is entitled to pre-judgment interest, and (e) the applicable pre-judgment interest rate. Therefore, this opinion concerns only the defendants' liability.
Obaid may move, with supporting evidence, for the Court to determine the dollar amount of disability benefits that were improperly withheld from Obaid and to award pre-judgment interest, attorney's fees, and costs.