UNPUBLISHED
UNITED STATES COURT OF APPEALS
FOR THE FOURTH CIRCUIT
No. 04-2243
FRANK J. FORMICA,
Plaintiff - Appellant,
versus
PRUDENTIAL INSURANCE COMPANY OF AMERICA,
Defendant - Appellee.
Appeal from the United States District Court for the District of
Maryland, at Greenbelt. Peter J. Messitte, District Judge. (CA-
00-3049-PJM)
Argued: December 2, 2005 Decided: January 19, 2006
Before WILKINSON and MICHAEL, Circuit Judges, and HAMILTON, Senior
Circuit Judge.
Affirmed by unpublished per curiam opinion.
ARGUED: Frederic Willard Schwartz, Jr., Washington, D.C., for
Appellant. Walter Laurence Williams, WILSON, ELSER, MOSKOWITZ,
EDELMAN & DICKER, L.L.P., McLean, Virginia, for Appellee. ON
BRIEF: James Taglieri, CADEAUX, TAGLIERI & NOTARIUS, Washington,
D.C., for Appellant. Laura Steel, Thomas P. Turgeon, WILSON,
ELSER, MOSKOWITZ, EDELMAN & DICKER, L.L.P., Baltimore, Maryland,
for Appellee.
Unpublished opinions are not binding precedent in this circuit.
See Local Rule 36(c).
PER CURIAM:
Frank Formica brings suit under the Employee Retirement Income
Security Act of 1974 (ERISA), 29 U.S.C. § 1001 et seq. (2000),
claiming that Prudential Insurance Company has wrongfully denied
him long-term disability benefits for his back pain. Formica filed
for these benefits just prior to leaving his position as a vice
president of the National Association of Securities Dealers. Under
the terms of the insurance policy that the NASD had purchased from
Prudential, Formica is to receive benefits for a “[t]otal
disability” if “Prudential determines,” inter alia, that he is “not
able to perform, for wage or profit, each and every of the material
and substantial duties of [his] occupation.” After commissioning
three independent physicians and an in-house doctor to review his
claim and affording him three internal appeals, Prudential
determined that Formica did not meet this standard. We agree with
the district court that this determination was a reasonable one,
and we therefore affirm its grant of summary judgment to
Prudential.
In reviewing Prudential’s determination, the district court
properly applied a modified abuse of discretion standard. “When an
ERISA plan affords an administrator discretion, a court reviews the
administrator’s decision to deny benefits for an abuse of that
discretion, asking whether the denial of benefits was reasonable.”
Stup v. UNUM Life Ins. Co. of Am., 390 F.3d 301, 307 (4th Cir.
2
2004). The plan here provides that a claimant is totally disabled
when “Prudential determines” that he meets the written
requirements, and Formica conceded in his filings before the
district court that Prudential had “discretion to determine
benefits questions.” The district court therefore correctly
reviewed Prudential’s decision for reasonableness, reducing its
level of deference somewhat to account for the potential conflict
of interest between Prudential’s dual roles as both plan
administrator and insurer. See id. (noting that such circumstances
may require more objective reasonableness and a greater showing of
evidentiary support).
Applying this deferential standard of review, the district
court found in favor of Prudential on two alternative grounds.
First, it concluded that Prudential had reasonably interpreted the
terms of the plan when it determined that to show himself unable to
perform “each and every” duty of his occupation, Formica would need
to demonstrate that he could not carry out any of the functional
requirements of his position. See also Gallagher v. Reliance
Standard Life Ins. Co., 305 F.3d 264, 270 (4th Cir. 2002)
(interpreting similarly worded ERISA plan in the same manner).
Formica does not contend that he can make such a showing.
Second, the district court concluded that Prudential would
prevail even under Formica’s more permissive reading of the plan,
which would grant him benefits if he were disabled from only some
3
of his duties. Again applying the deferential standard of review,
the court determined that Prudential could reasonably conclude from
the record that Formica was in fact able to perform each and every
one of his material job functions. The court examined the reports
of the various doctors who evaluated Formica, and found that
Prudential reasonably determined that the medical evidence did not
corroborate Formica’s subjective assessment of his condition. The
district court particularly emphasized the results of an
independent doctor’s physical exam, which concluded that Formica’s
“complaints of pain far outstrip objective findings.”
We find no error in the conclusions of the district court.
Its judgment is therefore
AFFIRMED.
4