Sisto, Elvira v. Ameritech Sickness ( 2005 )

In the
United States Court of Appeals
For the Seventh Circuit
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No. 03-4126
ELVIRA SISTO,
Plaintiff-Appellant,
v.
AMERITECH SICKNESS AND ACCIDENT
DISABILITY BENEFIT PLAN,
Defendant-Appellee.
____________
Appeal from the United States District Court
for the Northern District of Illinois, Eastern Division.
No. 01 C 8262—William T. Hart, Judge.
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ARGUED OCTOBER 28, 2005—DECIDED NOVEMBER 21, 2005
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Before EASTERBROOK, MANION, and ROVNER, Circuit Judges.
MANION, Circuit Judge. Ameritech Corporation employed
Elvira Sisto as a customer service representative. While
working at Ameritech, Sisto participated in the Ameritech
Sickness and Accident Disability Benefit Plan (“the plan”).
After slipping and falling in an Ameritech restroom, Sisto
sought benefits under the plan. The plan awarded Sisto
sickness benefits but denied accident benefits. Sisto sued.
The district court granted the plan summary judgment. Sisto
appeals. We affirm.
2 No. 03-4126
I.
As an Ameritech customer service representative, Elvira
Sisto fielded telephone calls from customers while sit-
ting at a computer terminal. On October 27, 1999, she
arrived at work shortly before her shift, flipped on her
computer, and, as was her normal practice, went to the
restroom while her computer was booting up. In the rest-
room, she slipped and fell. Her resulting injuries caused her
to miss work for a period. She returned in January 2000 and
worked through July 2000. However, she stopped working
in August 2000 due to the continued pain from her fall.
Sisto then sought disability benefits from the Ameritech
Sickness and Accident Disability Benefit Plan. The plan
administers two types of benefits. Sickness benefits cover
disabilities that are caused by illnesses or injuries unre-
lated to work. Such benefits are limited to a maximum of
fifty-two weeks. Accident benefits, by contrast, are for
disabling illnesses or injuries that result from a work-related
accident and can last as long as the disability lasts. The plan
(through a trained agent, Una Prezell, R.N.) awarded Sisto
full sickness benefits. However, finding that her accident
did not occur during the course of her employment, the plan
determined that she was ineligible for accident benefits and
thereby denied that portion of her claim.1
Dissatisfied, Sisto filed a state court action, which was
removed to federal court based upon a federal question, i.e.,
a denial of benefits claim under the Employee Retirement
Income Security Act. Ultimately, the district court granted
the plan’s motion for summary judgment, concluding that
1
Sisto also received worker’s compensation for the slip and
fall in Ameritech’s restroom.
No. 03-4126 3
the denial of accident benefits could not be reversed under
the governing arbitrary-and-capricious standard. Sisto
appeals.
II.
The sole issue on appeal is Sisto’s challenge to the
denial of accident benefits. See 29 U.S.C. § 1132(a)(1)(B).
Sisto contends that the district court erred in upholding the
denial. Our review of the district court’s summary judgment
decision is de novo. See Tegtmeier v. Midwest Operating
Eng’rs Pension Trust Fund, 390 F.3d 1040, 1045 (7th Cir.
2004). Summary judgment is appropriate when “the plead-
ings, depositions, answers to interrogatories, and admis-
sions on file, together with the affidavits, if any, show that
there is no genuine issue as to any material fact and that the
moving party is entitled to a judgment as a matter of law.”
Fed. R. Civ. P. 56(c).
When, as here, the terms of an employee benefit plan
clearly give the plan administrator broad discretion to
interpret the plan and determine benefit eligibility, our
review of the administrator’s denial is limited to the
arbitrary-and-capricious standard. See Diaz v. Prudential Ins.
Co. of Am., 424 F.3d 635, 637 (7th Cir. 2005); Tegtmeier, 390
F.3d at 1045. Sisto concedes that this highly deferential
standard applies. Under this standard, we will uphold
the plan’s decision “as long as (1) it is possible to offer a
reasoned explanation, based on the evidence, for a particu-
lar outcome, (2) the decision is based on a reasonable
explanation of relevant plan documents, or (3) the adminis-
trator has based its decision on a consideration of the
relevant factors that encompass the important aspects of the
problem.” Houston v. Provident Life & Accident Ins. Co., 390
4 No. 03-4126
F.3d 990, 995 (7th Cir. 2004) (quoting Hess v. Hartford Life &
Accident Ins. Co., 274 F.3d 456, 461 (7th Cir. 2001)); see also
Tegtmeier, 390 F.3d at 1045 (“[T]he administrator’s decision
will only be overturned if it is ‘downright unreasonable.’ ”
(quoting Carr v. Gates Health Care Plan, 195 F.3d 292, 295 (7th
Cir. 1999))).
As indicated above, eligibility for accident benefits turns
on whether the accident that caused the disabling injury
occurred in the course of employment. The pivotal plan
provision on this question is § 4.5. This section, in pertinent
part, states: “Accidental injuries shall be considered as
arising out of, and in the course of employment, only where
the injury has resulted solely from an accident during and in
direct connection with the performance of duties to which the
Eligible Employee is assigned by the Company or a Partici-
pating Company or which he or she is directed to perform
by proper Company or Participating Company authority or
if voluntarily protecting the Company’s or Participating
Company’s property or interests.” Plan § 4.5 (emphasis
added).
The plan determined that slipping and falling in the
restroom was not an accident that occurred “during and in
direct connection with” Sisto’s performance of her em-
ployment duties. Ameritech customer service representa-
tives sit at desks, work on computers, and answer tele-
phone calls for extended periods. Under the plan’s view,
using the restroom does not come within the scope of those
assigned employment duties. According to the plan, Sisto
was not performing any duty on behalf of Ameritech when
she was in the restroom.2 Consequently, the plan con
2
The plan places no importance on the fact that Sisto’s rest-
(continued...)
No. 03-4126 5
cluded that Sisto’s accident fell outside § 4.5’s “during
and in direct connection with” threshold and thus denied
Sisto accident benefits.
The plan’s explanation is reasonable. The plan interpreted
§ 4.5 narrowly, defining employment duties to only cover an
employee’s actual tasks performed for the direct benefit of
the employer (e.g., answering the telephone) and not
collateral matters such as attending to personal needs in the
restroom. Given the limiting language—“during and in
direct connection with”—the plan’s strict approach is, at the
very minimum, a “rational” application of § 4.5 to the facts
in this record. Leipzig v. AIG Life Ins. Co., 362 F.3d 406, 409
(7th Cir. 2004). Restated, there is nothing irrational about
defining employment duties as the literal duties of employ-
ment for which the employee was hired and paid to per-
form. As a result, the plan’s actions here were neither
arbitrary nor capricious. Cf. Recupero v. New England Tel. &
Tel. Co., 118 F.3d 820, 823, 838 (1st Cir. 1997) (confronting
identical accident plan language and reaching the same
conclusion when the injury occurred during a coffee break
away from the employee’s workstation).
Sisto argues for a broader application of § 4.5, putting
forth reasons why using the restroom at work is an indivisi-
ble part of performing one’s employment duties. For
instance, Sisto points out that use of the restroom enables
one to perform job tasks at a desk for hours at a time. Be
that as it may, Sisto is simply raising points of disagreement
with the plan’s decision to interpret § 4.5 narrowly. Raising
(...continued)
room accident occurred shortly before her shift began. According
to the plan, its decision in this matter would be the same if the
same accident had occurred during Sisto’s shift.
6 No. 03-4126
debatable points does not entitle Sisto to a reversal under
the arbitrary-and-capricious standard. Under this standard,
“questions of judgment are left to the [plan] administrator,”
Trombetta v. Cragin Fed. Bank for Sav. Employee Stock Owner-
ship Plan, 102 F.3d 1435, 1438 (7th Cir. 1996), and “[i]t is not
our function to decide whether we would reach the same
conclusion” as the administrator, Tegtmeier, 390 F.3d at 1045(quoting Carr, 195 F.3d at 294). Since the application of the
plan’s text and the resulting denial of accident benefits are
reasonable, we will not overturn that denial. See Tegtmeier,
390 F.3d at 1045; Houston, 390 F.3d at 995.
III.
Due to her disabling injuries, the plan awarded Sisto
full sickness benefits. Nonetheless, the plan denied Sisto
accident benefits because it determined that her slip and fall
in the restroom was not an accident “during and in direct
connection with” her employment duties as a customer
service representative. Drawing a line between tasks
performed for the direct benefit of the employer and actions
taken for the direct benefit of the employee is a reasonable
way to interpret, apply, and administer this plan. Accord-
ingly, under the arbitrary-and-capricious standard, we will
not disturb the plan’s denial of accident benefits. The
judgment of the district court is AFFIRMED.
No. 03-4126 7
A true Copy:
Teste:
_____________________________
Clerk of the United States Court of
Appeals for the Seventh Circuit
USCA-02-C-0072—11-21-05