Defendant Empire Blue Cross and Blue Shield (“Empire”) appeals from a judgment entered in the United States District Court for the Southern District of New York, following a bench trial before Robert W. Sweet,
Judge,
ordering Empire, an insurance company that administers a plan covered by ERISA, 29 U.S.C. § 1001
et seq.
(1994), to reimburse plaintiff Katherine Whitney, as Executrix of the Estate of Barbara Whitney (“Whitney”), for the cost of Whitney’s treatment for advanced breast cancer by means of high-dose chemotherapy followed by autolo-gous bone marrow transplant or stem cell support, recommended by her doctors.
The district court, following principles enunciated by the Eleventh Circuit in
Brown v. Blue Cross & Blue Shield,
Empire, in determining Whitney’s claim, was subject to the influence of a substantial conflict. Empire is at financial risk if the cost of its claims exceeds the premiums it has collected. The ultimate decision to approve or deny coverage resides in Empire’s medical director. Empire was administering claims under a policy it issued and for which it was financially responsible. This is the circumstance under which courts have held repeatedly that the insurance company is operating under an inherent conflict of interest:
Because an insurance company pays out to beneficiaries from its own assets rather than the assets of a trust, its fiduciary role lies in perpetual conflict with its profit-making role as a business.
[presented with Whitney’s claim, Empire was faced with the conflict of interest inherent to an insurer acting as plan administrator and was particularly conflicted because of the prospect of an unusually expensive benefit in a high-incidence disease. Under these circumstances, the denial of coverage must be reviewed with a significantly reduced level of deference.
After the district court issued its decision in the present case, we rendered our opinion in
Sullivan,
which expressly rejected the standard enunciated in
Brown.
We noted the
Brown
court’s holding that “ ‘[t]he inherent conflict between the fiduciary role and the profit-making objective of an insurance company makes a highly deferential standard of review inappropriate,’ ”
Sullivan,
we decline to concur with the rule in Brown and adhere to the arbitrary and capricious standard of review in cases turning on whether the decision was based on an alleged conflict of interest, unless the conflict affected the choice of a reasonable interpretation.
_ [I]n cases where the plan administrator is shown to have a conflict of interest, the test for determining whether the administrator’s interpretation of the plan is arbitrary and capricious is as follows: Two inquiries are pertinent. First, whether the determination made by the administrator is reasonable, in fight of possible competing interpretations of the plan; second, whether the evidence shows that the administrator was in fact influenced by such conflict. If the court finds that the administrator was in fact influenced by the conflict of interest, the deference otherwise accorded' the administrator’s decision drops away and the court interprets the plan de novo.
Sullivan,
In addition, we noted our rejection of the burden-shifting approach used by the
Brown
court, which placed the onus of disproving an actual influence of a conflict of interest on the plan. We stated that such an approach is “contrary to the traditional burden of proof in a civil ease” and that “the burden of proving that the conflict of interest affected the administrator’s decision rests with the plaintiffs.”
Sullivan,
Since this Court, in deciding a case on direct review, must apply the law as it exists at the time of our ruling,
see, e.g., Harper v. Virginia Department of Taxation,
No costs.
