935 F. Supp. 2d 278
D. Mass.2013Background
- Petrone, a DePuy Orthopaedics employee, sought continued LTD benefits under J&J’s ERISA plan after back surgery and pain.
- The plan denied continued LTD based on clinical grounds and a claimed failure to cooperate with plan procedures.
- Numerous physicians issued conflicting views: several found total disability; others found potential for sedentary or light work.
- SSDI awarded Petrone disability, which the plan did not fully engage with in its decision.
- The plan’s final denial occurred April 27, 2010; Petrone filed suit in 2011 seeking review and benefits.
- The court applied an abuse-of-discretion standard due to vested discretionary authority in the plan administrator.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether the denial was an abuse of discretion on clinical grounds | Petrone’s contrary medical evidence was ignored | McDonald’s decision was reasonable and supported by record evidence | Plan abused discretion; remand required |
| Whether a conflict of interest affected the decision | Johnson & Johnson’s ownership and funding create bias | Conflict is attenuated and does not dictate outcome | Conflict present but attenuated; not dispositive; remand warranted |
| Whether the decision failed to address adverse medical evidence | Plan ignored key opinions (Marcovici, Worthington, Dominguez) | Plan relied on substantial other evidence | Failure to address adverse evidence constitutes abuse of discretion; remand warranted |
| Whether the plan properly considered the SSA decision | SSA decision should inform LTD determination | SSA not binding but informative | Plan’s disregard of SSA evidence improper; remand for fuller consideration |
| Whether remand is appropriate to cure process deficiencies | Remand to plan administrator for further proceedings consistent with opinion |
Key Cases Cited
- Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101 (1989) (establishes deferential review when plan grants discretion)
- Conkright v. Frommert, 559 U.S. 506 (2010) (upholds deferential review where discretion exists)
- Vlass v. Raytheon Employees Disability Trust, 244 F.3d 27 (1st Cir. 2001) (requires substantial evidence to support administrator’s decision)
- Buffonge v. Prudential Co. of Amer., 426 F.3d 20 (1st Cir. 2005) (remand when integrity of decision making is questioned)
- Richards v. Hewlett-Packard Corp., 592 F.3d 232 (1st Cir. 2010) (SSA determinations are not binding but informative)