pain and need to urinate, she had discontinued the medication because her
insurance did not cover it. Drs. Simon and Sproul agreed that Gomoluch
could work at a sedentary job if she was allowed bathroom breaks when
needed and could take Elmiron regularly.
The Assistant Secretary to the Benefit Committee, Kathy Ort,
subsequently received Gomoluch's file. Ort prepared a report for the
Benefit Committee that summarized Gomoluch's case and recommended
upholding the termination. Dr. Anfield, the medical advisor to the Benefit
Committee, agreed with Ort's recommendation.
Nikitas distributed Gomoluch's entire file to the Benefit Committee
several days before it met to vote on Gomoluch's appeal. Gomoluch's file
contained her appeal letter; her medical records; notes from plan
administrators regarding her claim; letters from treating physicians
dated August 28 and November 1, 1996; Dr. Sproul's December 18, 1996
letter; Dr. Simon's handwritten notes; and Ort's recommendation and
Dr. Anfield and Ort attended the Benefit Committee meeting held on May
27, 1997. Dr. Anfield summarized the information contained in Gomoluch's
file, discussing the medical findings and their significance, and
answered the members' questions regarding Gomoluch's condition. The
Committee voted to uphold the termination of Gomoluch's long-term
benefits. On June 5, 1997, Ort sent a letter to Gomoluch informing her
that the Committee voted to deny Gomoluch's benefits "due to a lack of
objective medical documentation to substantiate" her claim that she was
"unable to engage in any occupation or employment (with reasonable
accommodation), for which [she was] qualified, or may reasonably become
qualified, based on training, education or experience." This suit
SUMMARY JUDGMENT STANDARD
Summary judgment is proper when there is no genuine issue of material
fact and the moving party is entitled to judgment as a matter of law.
Fed.R.Civ.P. 56(c). To avoid summary judgment, the nonmovant must
advance "specific facts showing that there is a genuine issue for trial."
Fed.R.Civ.P. 56(e). A genuine issue for trial exists when "the evidence
is such that a reasonable jury could return a verdict for the nonmoving
party." Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 248, 106 S.Ct.
2505, 91 L.Ed.2d 202 (1986).
In analyzing an ERISA claim under § 1132(a), we must first
determine the appropriate standard of review. The Supreme Court instructs
us that, "a denial of benefits challenged under § 1132(a)(1)(B) 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." See
Firestone Tire and Rubber Co. v. Bruch, 489 U.S. 101, 115, 109 S.Ct.
948, 103 L.Ed.2d 80 (1989). In the instant case, both parties agree that
the Benefit Committee had full discretionary authority to interpret the
LTDP's terms and to determine benefits eligibility. Therefore, to survive
Defendants' motion for summary judgment, Gomoluch must submit evidence
demonstrating that Defendants' benefits determination was arbitrary and
capricious. Fuller v. CBT Corp., 905 F.2d 1055, 1058 (7th Cir. 1990).
1. Decision to Deny Benefits
Under the arbitrary and capricious standard, we must give substantial
deference to the Benefit Committee's determination. Wilczynski v. Kemper
Nat'l Ins. Cos., 998 F. Supp. 931, 942 (N.D.Ill. 1998). To hold that the
Benefit Committee's decision was arbitrary and capricious, we must be
confident that the Committee "failed to
consider significant information or that they seriously erred in
evaluating the evidence before them." Gupta v. Freixenet, USA, Inc.,
908 F. Supp. 557, 565-65 (N.D.Ill. 1995); see also Wahlin v. Sears,
Roebuck & Co., 78 F.3d 1232, 1235 (7th Cir. 1996). The decision of the
Benefit Committee will not stand if it
relied on factors which Congress has not intended it
to consider, entirely failed to consider an important
aspect of the problem, offered an explanation for its
decision that runs counter to the evidence before
[it], or is so implausible that it could not be
ascribed to a difference in view or the product of
Gawrysh v. CNA Ins. Co., 8 F. Supp.2d 791, 794 (N.D.Ill. 1998) (quoting
Motor Vehicle Mfrs. Assoc. v. State Farm, Mut. Auto. Ins. Co., 463 U.S. 29,
43, 103 S.Ct. 2856, 77 L.Ed.2d 443 (1983)). Thus, we must uphold the
Benefit Committee's decision unless we find that it was "downright
unreasonable". See Donato v. Metropolitan Life Ins. Co., 19 F.3d 375, 380
(7th Cir. 1994).
Gomoluch argues that the Benefit Committee's decision to uphold the
termination of her long-term disability benefits was arbitrary and
capricious because Ort's summary report brushed over language used in
Dr. Sproul's December 18th letter that supported Gomoluch's case.
Specifically, Gomoluch points out that Ort's report failed to incorporate
Dr. Sproul's observation that "[i]t is difficult for her to maintain a
schedule that will allow her to work regularly."
Even if the Court were to conclude that Ort's summary report is
incomplete or even slanted, Ort's report was merely a summary of the
evidence presented to the Benefit Committee. Although Ort recommended
denying Gomoluch's claim, the Committee was not bound by her report or
recommendation. To the contrary, the evidence shows that the Benefit
Committee received and reviewed Gomoluch's entire disability file. In
addition to Ort's report, Gomoluch's file contained her handwritten
appeal letter; her medical records; notes from plan administrators
regarding her claim; letters from treating physicians; Dr. Sproul's
December 18, 1996 letter; and Dr. Simon's handwritten notes.
Moreover, the Committee's denial would have been reasonable even if
Dr. Sproul's opinion was the only evidence submitted. While the letter
indicates that Gomoluch has difficulty working, Dr. Sproul conceded that
as long as Gomoluch was provided bathroom breaks when needed and could
take Elmiron, she could work a sedentary job. Such an opinion does not
render the Benefit Committee's decision downright unreasonable.*fn1
Therefore, we uphold the Benefit Committee's decision as reasonable under
2. Notification of Denial
Gomoluch also takes issue with Amentech's letter denying her benefits,
complaining that it fails to comport with § 5.2 of Ameritech's LTDP.
Section 5.2 mirrors the requirements ERISA imposes on all benefit plans
pursuant to 29 U.S.C. § 1133, which directs plans to provide
unsuccessful claimants with written notification of the denial. The
regulations promulgated pursuant to 29 U.S.C. § 1133 describe the
notice requirements in detail. 29 C.F.R. § 2560.503-1 (f). Denial
letters must inform unsuccessful claimants of
(1) The specific reason or reasons for the denial;
(2) Specific reference to pertinent plan provisions on
which the denial is based;
(3) A description of any additional information
necessary for the claimant to perfect the claim
and an explanation
of why such material or information is necessary;
(4) Appropriate information as to the steps to be
taken if the participant or beneficiary wishes to
submit her claim for review.
Id.; see also Halpin v. W.W Grainger, Inc.,