United States District Court, M.D. Florida, Fort Myers Division
MIRANDO United States Magistrate Judge.
matter comes before the Court upon review of Plaintiff Mark
Atherley's Motion Regarding Applicable Standard of Review
filed on December 22, 2017. Doc. 28. Plaintiff is seeking an
order setting the standard of review in this case as de
novo. Defendant UnitedHealthcare of Florida, Inc.
(“United”) filed a Response in Opposition to
Plaintiff's Motion on January 5, 2018, requesting that
the Court apply the arbitrary and capricious standard of
review to this case. Doc. 29. For the reasons discussed
below, the Court finds the appropriate standard of review for
this case is the arbitrary and capricious standard.
Summary of Background
an action by Plaintiff to enforce rights and seek damages
under the Employee Retirement Income Security Act, 29 U.S.C.
§ 1001, et seq. (“ERISA”) against
United for denying health insurance benefits to which
Plaintiff allegedly was entitled under his United group
health insurance plan (the “Plan”). Doc. 1 at
7-12. Specifically, Plaintiff seeks the recovery of benefits
under 29 U.S.C. § 1132(a)(1)(B), administrative
penalties under 29 U.S.C. §§ 1132(c)(1), 1024(b)
and 29 C.F.R. § 2575.502c-1, and attorneys' fees
under 29 U.S.C. § 1132(g)(1). Id.
had health insurance benefits through the Plan, which was
offered by his employer, Southwest Florida Maritime, Inc.
(“Southwest”), and administered by United.
Id. ¶ 7. Plaintiff needed a life-saving liver
transplant, without which he was expected to survive only
until July 2015. Id. ¶ 8. United allegedly
authorized a liver transplant for Plaintiff, but the
in-network medical provider that United referred him to was
either unwilling or unable to perform the procedure before
July 2015. Id. Plaintiff attempted to find another
in-network provider through his United “advocate,
” but the medical provider suggested by the advocate
failed to timely communicate with Plaintiff. Id.
¶ 9. Therefore, Plaintiff independently identified a
Florida medical provider that could perform the liver
transplant- Cleveland Clinic in Weston, FL-and he
successfully underwent the procedure in July 2015.
Id. ¶ 10.
Clinic billed United for the liver transplant and associated
medical services, but United refused to provide coverage for
the procedure. Id. ¶ 11. As a result, Plaintiff
had to prematurely withdraw from his retirement savings to
pay the approximately $290, 000 bill. Id.
Plaintiff's counsel attempted to resolve the issue with
United through pre-suit communications, but according to
Plaintiff, United's in-house counsel “eventually
fell off the map.” Id. at ¶¶ 18-19,
28-35. Therefore, Plaintiff initiated this action.
Available Standards of Review
ERISA does not prescribe a particular standard of review for
decisions made by plan administrators or fiduciaries, there
are two possible options: (1) the arbitrary and capricious
standard, which applies when the benefit plan gives the
administrator “discretionary authority to determine
eligibility benefits or construe the terms of the plan,
” or (2) the de novo standard, which applies
in the absence of such discretionary authority. Metro.
Life Ins. Co. v. Glenn, 554 U.S. 105, 111, 117-19
(2008); Firestone Tire & Rubber Co. v. Bruch,
489 U.S. 101, 115 (1989); Blankenship v. Metro. Life Ins.
Co., 644 F.3d 1350, 1355-56 (11th Cir.
2011). The applicable standard of review
ultimately impacts the six-step analysis for reviewing an
administrator's benefits decision:
(1) Apply the de novo standard to determine whether
the claim administrator's benefits-denial decision is
“wrong” (i.e., the court disagrees with the
administrator's decision); if it is not, then end the
inquiry and affirm the decision.
(2) If the administrator's decision in fact is
“de novo wrong, ” then determine whether
he was vested with discretion in reviewing claims; if not,
end judicial inquiry and reverse the decision.
(3) If the administrator's decision is “de
novo wrong” and he was vested with discretion in
reviewing claims, then determine whether
“reasonable” grounds supported it (hence, review
his decision under the more deferential arbitrary and
(4) If no reasonable grounds exist, then end the inquiry and
reverse the administrator's decision; if reasonable
grounds do exist, then determine if he operated under a
conflict of interest.
(5) If there is no conflict, then end the inquiry and affirm
(6) If there is a conflict, the conflict should merely be a
factor for the court to take into account when determining
whether an administrator's ...