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Solivan v. Com. Ed. Mut. Benefit Ass'n

OPINION FILED JULY 15, 1986.

EMERITO SOLIVAN, PLAINTIFF-APPELLEE AND CROSS-APPELLANT,

v.

COMMONWEALTH EDISON MUTUAL BENEFIT ASSOCIATION, DEFENDANT-APPELLANT AND CROSS-APPELLEE.



Appeal from the Circuit Court of Cook County; the Hon. Alan E. Morrill, Judge, presiding.

JUSTICE SCARIANO DELIVERED THE OPINION OF THE COURT:

Plaintiff-appellee, Emerito Solivan, after being denied continued-disability benefits by defendant-appellant Commonwealth Edison Mutual Benefit Association (hereinafter the association), initiated this action seeking reinstatement of the terminated benefits. In essence, Solivan asserted that the association's actions were either arbitrary and capricious, or were taken in bad faith. Both parties filed motions for summary judgment. After a hearing on the motions, the circuit court granted Solivan reinstatement, although it denied his request for attorney fees. The court also denied the association's summary judgment motion. On appeal, the association assails the court's decision to grant Solivan summary judgment; Solivan on cross-appeal claims the court erred in denying him attorney fees. We affirm.

The facts of the case are not substantially in dispute. Emerito Solivan was employed by Commonwealth Edison as a meter reader, commencing employment on January 2, 1979. As a result of this employment, Solivan joined the association, which was a voluntary, unincorporated association designed to provide its members with disability coverage. The parties to this appeal agree that the disability plan involved in this case is governed by the provisions of the Employee Retirement Income Security Act (hereinafter ERISA) (29 U.S.C. § 1001 et seq. (1985)).

On August 10, 1981, Solivan fractured his left leg while playing baseball. As a result of the injury, he was placed on disability from that date through March 1, 1982. On August 27, 1982, a metal plate which had been placed on the fracture was removed, occasioning a second absence from work dating from August 27, 1982, until October 12, 1982, and benefits were paid for this second absence. When Solivan returned to work, the fracture had completely healed.

On January 9, 1983, Solivan again fractured his left leg, this time while dancing. The fracture was located at the same site as the initial break. As with the initial fracture, Solivan again requested disability benefits from the association.

The key provisions at issue herein as contained in the ERISA plan are the following:

"Rule C(5) RELAPSE

If the member is absent on disability and returns to full-time work, another absence for the same cause shall be termed a "Relapse" and will be considered a continuation of the previous disability in either of the following circumstances:

(b) the previous absence exceeded 26 weeks and the second absence occurs within one year of the return to work full-time.

Rule A(6)(d) REINSTATEMENT

A member who returns to work after having received 52 weeks of benefits for any one case of disability may be reinstated by unanimous approval by the Board after consultation with its Medical Advisor. If, however, a member is approved for reinstatement, such member shall not be entitled to receive benefits for prior disability for which maximum benefits were paid or a disability arising out of, connected with, or resulting from the cause or effect of such prior disability." (Emphasis added).

Solivan received a pamphlet detailing these provisions prior to sustaining the injuries involved herein.

Upon Solivan's request for renewed disability benefits for the second fracture, Robert Stauder, the association's administrator, wrote Solivan and informed him that the association considered the injury to be a reoccurrence of the initial fracture, and that as a result the "relapse rule" would apply. Stauder's letter requested or invited Solivan to submit details regarding the injury if he disagreed with the association's judgment. This letter did not inform Solivan of the specific plan provision relied upon, nor did it set out the procedure by which Solivan could appeal the decision. Solivan wrote Stauder, stating that the injury was not a reoccurrence of the prior disability, but was caused by moisture and debris on the dance floor which caused him to fall and fracture the leg. Solivan submitted X rays for review by the association. In a letter dated May 26, 1983, Solivan was informed that his benefits had expired as of that date.

In November 1983, Solivan appeared before the association's executive board to appeal the decision. The board was provided with Solivan's medical records, although Solivan did not provide any expert medical opinion as to the injury. The board, in a letter dated November 10, 1983, advised Solivan that his appeal had been denied.

Solivan then instituted this action in the circuit court, asserting that the board's decision was arbitrary and capricious, or was taken in bad faith. As noted, a hearing was held on the cross-motions for summary judgment on May 15, 1985. The circuit court, after noting that the second fracture was caused by a second traumatic incident, found that the board's position in denying benefits was "grossly incorrect," and granted Solivan's motion for a summary judgment.

OPINION

On appeal, the association attacks the circuit court's decision on several grounds. First, the association asserts that the court failed to apply the appropriate, deferential standard of review mandated for court review of the administration of ERISA plans. Next, assuming that the correct standard was applied, the association claims that the circuit court must be reversed as Solivan failed to meet that standard. Finally, the association decries the circuit court's usage of a State court decision in reaching its determination in this case. Solivan, meanwhile, challenges the court's denial of his request for attorney fees.

• 1 We address first the question of the appropriate standard of review. ERISA, by its explicit language, evinces a strong congressional mandate to preempt State law and regulation of employee benefit plans falling under its purview, and to substitute in its place a uniform Federal common law to govern the administration of such plans. (29 U.S.C. par. 1144(a) (1985).) This Federal common law would be applicable to all suits brought under ERISA, whether in State or Federal court. (Reiherzer v. Shannon (7th Cir. 1978), 581 F.2d 1266, 1271.) In analyzing the administration of ERISA plans, a relatively deferential standard of review was adopted: the findings of the plan's administrators are to be upheld by the court unless they re found to be either (1) arbitrary and capricious; (2) not supported by substantial evidence; or (3) erroneous on a question of law. (Wardle v. Central Southeast & Southwest Areas Pension Fund (7th Cir. 1980), 627 F.2d 820, 824.) This standard of review is applied in order to avoid excessive judicial intervention in, and interference with, the administration of ERISA plans. (Miles v. New York State Teamsters Conference Pension & Retirement Fund Employee Pension Benefit Plan (2d Cir. 1983), 698 F.2d 593, 599.) Rather, ERISA seeks to place the primary responsibility for plan administration on the board created by the ...


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