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04/23/97 MARIE A. BOYD v. PEORIA JOURNAL STAR

April 23, 1997

MARIE A. BOYD, PLAINTIFF-APPELLANT,
v.
PEORIA JOURNAL STAR, INC., AN ILLINOIS CORPORATION, DEFENDANT-APPELLEE.



Appeal from the Circuit Court of the 10th Judicial Circuit, Tazewell County, Illinois. No. 94-L-5. Honorable Donald C. Courson, Judge, Presiding.

Rehearing Denied May 27, 1997. Released for Publication May 27, 1997.

Present - Honorable Tom M. Lytton, Presiding Justice, Honorable Kent Slater, Justice, Honorable John F. Michela, Justice. Justice Michela delivered the Opinion of the court. Lytton, P.j., and Slater, J., concurred.

The opinion of the court was delivered by: Michela

The Honorable Justice MICHELA delivered the Opinion of the court:

Marie A. Boyd, filed an action in the circuit court of Tazewell County against her employer, Peoria Journal Star, Inc., seeking recovery for medical expenses under a health insurance plan known as "The Peoria Journal Group Health Benefit Plan" (the Plan). The court granted defendant's motion for summary judgment and denied plaintiff's counter-motion for summary judgment.

On appeal, plaintiff seeks reversal of the court's decision, contending that it erred in finding the Plan contained no provisions for, and specifically excluded coverage for, the surgical removal of her defective prosthesis. Plaintiff contends further that defendant's interpretation of the Plan was irrational, arbitrary, and capricious, in violation of the Employee Retirement Income Security Act (ERISA]=

Facts

In March 1983, plaintiff developed temporomandibular joint syndrome (TMJS), which necessitated the replacement of her temporomandibular joint (TMJ) with a TMJ implant (prosthesis).

In October 1993, plaintiff's oral surgeon, Dr. Russell A. Williams, notified defendant that due to resorption occurring around plaintiff's prosthesis, and the potential for brain exposure, her prosthesis must be removed. Dr. Williams informed defendant of his surgical plan, and surgery was scheduled for November 1993. Prior to surgery, defendant notified Dr. Williams and plaintiff of its denial of plaintiff's benefit claim.

In January 1994, plaintiff filed her complaint against defendant, which was later amended, and alleged, inter alia, that in violation of ERISA, defendant's decision to deny her benefits was based on an irrational, arbitrary, and capricious interpretation of the Plan.

In April 1994, plaintiff underwent surgical removal of her prosthesis at a reported cost of $30,000. In December 1994, defendant filed a motion for summary judgment, and in May 1995, plaintiff filed a counter-motion for summary judgment. In August 1995, the court granted defendant's motion, denied plaintiff's counter-motion, and plaintiff appeals.

Analysis

Plaintiff contends that the court erred in granting defendant's motion for summary judgment and in denying her counter-motion for summary judgment. A motion for summary judgment should be granted if the pleadings, depositions, and admissions on file, together with any affidavits, show that there is no genuine issue of material fact and that the moving party is entitled to a judgment as a matter of law. Boylan v. Martindale, 103 Ill. App. 3d 335, 339, 59 Ill. Dec. 43, 431 N.E.2d 62 (1982).

In this matter, plaintiff asserts that the court erred in finding that the Plan contained no provisions for, and specifically excluded coverage for, the surgical removal of her defective prosthesis. Plaintiff maintains that in violation of ERISA, defendant's ...


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