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COURI v. GUARDIAN LIFE INS. CO. OF AMERICA

December 3, 1996

PHILLIP E. COURI, Plaintiff
v.
GUARDIAN LIFE INSURANCE COMPANY OF AMERICA, Defendant.



The opinion of the court was delivered by: GETTLEMAN

 Plaintiff Phillip E. Couri has filed a one-count amended complaint challenging defendant Guardian Life Insurance Company of America's denial of dental benefits for plaintiff's dependent son under an employee welfare benefit plan governed by the Employment Retirement Income Security Act ("ERISA"), 29 U.S.C. § 1132(a)(1)(B). Plaintiff seeks injunctive relief, expenses, and attorney's fees. Defendant has filed the instant motion for summary judgment pursuant to Fed. R. Civ. P. 56. For the reasons set forth below, defendant's motion is denied.

 FACTS

 Defendant is a licensed insurance company incorporated under the laws of the state of New York. Defendant entered into an insurance policy agreement with Bartnell, Ltd. ("Bartnell"), for an employee welfare benefit plan governed exclusively by ERISA. Plaintiff, his spouse, and dependant children obtained coverage under defendant's plan with Bartnell, Group Health Plan # 197332 ("Group Plan").

 On July 25, 1993, plaintiff's son, Peter A. Couri ("Peter"), was involved in an accident and sustained a serious injury to his teeth and mouth as a result. Plaintiff reported the injury and submitted claims to defendant on August 25, 1993. Defendant reimbursed plaintiff for his initial emergency medical costs. The treating physicians and dentists informed plaintiff that Peter would need surgery and additional medical assistance, but that a major portion of the surgery and dental repair could not be performed for approximately one year because the injuries he sustained in the accident had to heal before the additional surgery could be safely performed.

 The Major Medical Expense Insurance section of the Group Health Plan contains the following provision:

 Doctor's Charges for Surgery : We cover doctor's charges for medically necessary surgery. We don't pay for cosmetic surgery. But we cover reconstructive surgery needed due to a sickness or injury. This surgery can be performed either at the same time as, or after, other needed surgery. We also cover reconstructive surgery needed due to a functional birth defect in a covered dependent child. [Emphasis added.]

 The "OTHER LIMITATIONS" provision of same section states:

 Dental Care and Treatment: We cover: (a) the diagnosis and treatment of oral tumors and cysts; and (b) the surgical removal of impacted teeth.

 We also cover treatment of an injury to natural teeth or the jaw, but only if: (a) the injury occurs while the covered person is insured; (b) the injury was not caused by biting or chewing; and (c) all treatment is finished within six months of the date of the injury. Treatment includes replacing natural teeth lost due to such injury. [Emphasis added.]

 Plaintiff submitted estimates and claims to defendant for Peter's proposed surgery and treatment in excess of $ 12,000. On March 24, 1995, defendant denied these claims because the treatment had not been completed within six months of the original accident. On May 11, 1995, plaintiff requested that defendant review its denial of claims. On June 6, 1995, defendant again denied coverage because all dental work had to be completed within six months of the original accident.

 Plaintiff's complaint was originally filed in Cook County Circuit Court. Defendant timely removed plaintiff's action to this court and filed a motion to dismiss pursuant to Fed.R.Civ.P. 12(b)(6). Thereafter, plaintiff filed a motion to remand the case to state court. On April 15, 1996, this court issued a memorandum opinion and order denying plaintiff's motion to remand and granting defendant's motion to dismiss without prejudice. Plaintiff filed an amended complaint on May 30, 1996, pursuant to which defendant brings the instant motion for summary judgment.

 DISCUSSION

 I. STANDARD OF ...


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