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UNIVERSITY OF CHICAGO HOSPS. v. CENTRAL STATES SOU

October 24, 1997

UNIVERSITY OF CHICAGO HOSPITALS, Plaintiff,
v.
CENTRAL STATES SOUTHEAST AND SOUTHWEST AREAS HEALTH AND WELFARE PLAN, ET AL, Defendants.



The opinion of the court was delivered by: SHADUR

 This action by the University of Chicago Hospitals ("Hospitals") against the Central States, Southeast and Southwest Areas Health and Welfare Fund and its Trustees (collectively "Fund") and Teamsters Union No. 142 Health and Welfare Fund and its Trustees (collectively "142 Fund") was originally brought in the Circuit Court of Cook County. Fund timely removed the action to this District Court, and on the following day (still within the 28 U.S.C. § 1146(b) 30-day time limit) 142 Fund consented in writing to the removal, thus perfecting it (see Roe v. O'Donohue, 38 F.3d 298, 301 (7th Cir. 1994)).

 After 142 Fund had moved for summary judgment under Fed. R. Civ. P. ("Rule") 56, on August 5, 1997 Hospitals voluntarily dismissed their claim against the 142 Fund defendants. As against Fund, however, Hospitals seek a declaration of health insurance coverage and the payment of medical bills incurred as a result of the hospitalization of Joseph Sever ("Sever"). Because this action involves employer-sponsored welfare benefit plans, it necessarily implicates the Employee Retirement Income Security Act of 1974 ("ERISA," 29 U.S.C. §§ 1001-1461), *fn1" thus supporting the removal of the action to this District Court.

 All remaining parties have now moved for summary judgment under Rule 56. They have complied with General Rule ("GR") 12(M) and 12(N), adopted by this District Court to facilitate the resolution of Rule 56 motions, under which the litigants must respectively submit factual statements in support of and in opposition to such motions. *fn2" With the cross-motions now fully briefed, the issues are ready for decision.

 For the reasons stated in this memorandum opinion and order, this Court holds that Fund did not arbitrarily and capriciously deny Sever's claim for medical benefits. Accordingly Fund's motion is granted, while Hospitals' is denied and this action is dismissed.

 Summary Judgment Standards

 Familiar Rule 56 principles impose on a party seeking summary judgment the burden of establishing the lack of a genuine issue of material fact ( Celotex Corp. v. Catrett, 477 U.S. 317, 322-23, 91 L. Ed. 2d 265, 106 S. Ct. 2548 (1986)). For that purpose this Court must "read[ ] the record in the light most favorable to the non-moving party," although it "is not required to draw unreasonable inferences from the evidence" ( St. Louis N. Joint Venture v. P & L Enters., Inc., 116 F.3d 262, 265 n.2 (7th Cir. 1997)). Where as here cross-motions for summary judgment are involved, it is necessary to adopt a dual perspective--one that this Court has often described as Janus-like--that sometimes involves the denial of both motions. That problem does not arise here because the underlying facts are not in dispute. Instead the parties are at odds about whether, as a matter of law, Fund's Trustees ("Trustees") properly exercised their duties as administrators of their benefit plan.

 Facts

 Fund has established an Employee Welfare Benefit Plan ("Plan") as a self-funded group health plan administered by Trustees pursuant to Articles IV and V of Fund's Trust Agreement ("Trust Agreement" or, where a specific provision is being cited, "TA")(CS 12(M) PP1-3; TA Art. IV § 17; TA Art. V § 2). Employees participate in the Plan "when their employers, pursuant to the requirements of collective bargaining agreements, negotiated with affiliates of the International Brotherhood of Teamsters, make contributions on their behalf to provide medical, dental, vision and life insurance coverage to covered participant[s] and their families" (CS 12(M) P8).

 On December 17, 1992 Trustees unanimously approved the acceptance into Fund coverage of 4200 actively employed participants from some 284 companies that had previously been contributing to the 142 Fund on behalf of those participants. Those new participants were subject to several conditions. Of particular importance to this case, medical coverage was conditional on a participant being deemed an "active employee" within the meaning of the Plan as of January 31, 1993 (id. PP12-14). *fn3"

 Sever was an employee of Central Distributing Company ("Central"), one of the companies that became a new contributor to Fund on January 31, 1993 (CS 12(M) P16; H. 12(N) PP6-7). As of that date Sever ceased to be an eligible participant in the 142 Fund (F. 12(M) P7). Instead Fund received health contributions from Central on Sever's behalf from January 31, 1993 through March 13, 1993 (CS 12(M) P22; H. 12(N) P8), suggesting that Sever was an active employee covered by the Plan. But both before and throughout that period Sever suffered from an advanced stage of amyotrophic lateral sclerosis ("ALS," commonly referred to as Lou Gehrig's Disease)(H. 12(N) P9). That illness affected Sever's upper and lower extremities and the muscles controlling his speech, swallowing and breathing (CS 12(M) P18).

 On February 15, 1993 Sever was admitted to Hospitals, where he remained until he was discharged on March 10, 1993 (CS 12(M) P19; H. 12(N) PP10-11). During that hospital stay Sever incurred approximately $ 100,000 in medical expenses (CS 12(M) P21). Sever died on the following day, March 11 (CS 12(M) P20; H. 12(N) P13).

 Sever's widow Darlene timely presented a claim to Trustees for all of the expenses incurred as a result of Sever's hospitalization (H. 12(N) P14). Due to the nature of Sever's illness, Trustees questioned whether he had been eligible for benefits under the Plan (CS Ex. 2 at 2). While Fund had initially paid $ 1,941.60 in benefits, *fn4" Trustees denied the remaining claims because they determined that Sever's medical condition precluded his having been an "active employee" as defined by the Plan on January 31, 1993, thus rendering him ineligible for coverage (CS 12(M) P23; H. 12(N) P15). *fn5"

 On February 18, 1994 Fund wrote Sever's widow a letter denying her claim for medical benefits on behalf of her husband (CS Ex. 2 at 16-18). In accordance with the ERISA procedures and requirements for notification when a plan administrator decides to deny a benefit claim (see 29 C.F.R. § 2560.503-1(f)), Fund gave the specific reason for that denial, referred to the pertinent plan provisions on which the denial was based, described any additional information that Sever's widow might have submitted to perfect the claim and explained the next step for appellate review. Sever's widow took all of the steps required to perfect a timely appeal of Trustees' denial of medical benefits, but to no avail (CS 12(M) P48; H. 12(N) P35). On May 25, 1994 the Level II Claim Appeal Committee denied the claimed benefits. And finally, on November 29, 1994 Trustees affirmed the denial of coverage in the Level III Claim Appeal Procedure, the final step in the review process.

 Before his discharge from the hospital, Sever had assigned his right to receive health benefits to Hospitals (CS 12(M) P50; H. 12(N) P36). In this action Hospitals as assignee sued Fund, alleging that Trustees had breached their fiduciary duties by arbitrarily and capriciously denying Sever's widow's claim for medical benefits (CS 12(M) P51; H. 12(N) P37).

 Breach of Duty Under ERISA

 ERISA Standard of Review

 ERISA § 1132(a)(1)(B) expressly authorizes suits by participants or their beneficiaries against fiduciaries and plan administrators to challenge benefit eligibility determinations, and Hospitals as assignee thus stand in the shoes of a permitted ERISA plaintiff. While ERISA itself does not prescribe the appropriate standard of judicial review for such actions, Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115, 103 L. Ed. 2d 80, 109 S. Ct. 948 (1989) has ...


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