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QUINN v. BLUE CROSS & BLUE SHIELD ASS'N

November 21, 1997

CONSUELA QUINN, Plaintiff,
v.
BLUE CROSS AND BLUE SHIELD ASSOCIATION, Defendant.



The opinion of the court was delivered by: SHADUR

 Consuela Quinn ("Quinn") has brought this Employee Retirement Income Security Act ("ERISA") action against Blue Cross and Blue Shield Association ("Blue Cross") under 29 U.S.C. § 1132(a)(1)(B). *fn1" Quinn seeks disability income benefits under an employee benefit plan administered by Blue Cross.

 Both sides have now moved for summary judgment under Fed.R.Civ.P. ("Rule") 56. They have complied with this District Court's Rule ("GR") 12(M) and 12(N) *fn2" and have now briefed the cross-motions fully, so that the motions are ready for decision. Although both motions must be denied for the reasons set forth in this memorandum opinion and order, this action is dismissed without prejudice, coupled with a direction to Blue Cross to deal with Quinn's claims appropriately.

 Summary Judgment Standards

 Facts

 Quinn began working at Health Care Service Corporation ("Health Care") in July 1990. Health Care is a licensee of Blue Cross doing business as Blue Cross and Blue Shield of Illinois. As a Blue Cross licensee, Health Care participates in its Non-Contributory National Long Term Disability Program ("Program") (BC 12(M) P7). Blue Cross sponsors, and a committee of its board of directors--the National Employee Benefits Committee("Benefits Committee")--administers, the Program. Funding for the Program, however, comes not from Blue Cross but exclusively from a trust financed by participating employer contributions (Q. 12(N) P15). Quinn became insured under the Program several months after she began working at Health Care.

 Quinn stopped working as a Health Care payroll accounts assistant on July 14, 1994 after receiving a hysterectomy. Health Care granted her short-term disability benefits while she recuperated from that operation. But the hysterectomy apparently exacerbated pelvic and urinary tract discomfort with which Quinn had a longstanding problem. In September 1994 Quinn underwent a cystoscopy (a direct visual examination of the bladder using a scope) that led her doctors to suspect that she suffered from interstitial cystitis, a non-bacterial inflammation of the urinary bladder that can cause pain and increased frequency of urination (Q. 12(N) P15). Quinn began to see Dr. Anthony Schaeffer, chairman of the Northwestern University Medical School Department of Urology, to treat her condition (BC 12(M) P37). Dr. Schaeffer confirmed that Quinn was suffering from interstitial cystitis and placed her on a treatment protocol (Q. 12(N) P32).

 In February 1995 Quinn, citing her interstitial cystitis, applied for long-term disability benefits under the Program. Blue Cross referred her to Dr. Dennis Pessis, also a urologist, for an independent medical exam on May 4, 1995 (Q. 12(N) P30). Dr. Pessis reported that Quinn should be off of work for at least four weeks to give Dr. Schaeffer's treatment a chance to take effect, at which point Dr. Schaeffer could re-evaluate Quinn for a possible return to work (BC 12(M) P48). Blue Cross later approved Quinn's benefits claim, retroactive to January 1, 1995 and continuing through August 31, 1995, so that Quinn could follow Dr. Schaeffer's treatment course and submit additional medical evidence (BC 12(M) P49; Grant Aff. P28).

 In late August Blue Cross again consulted with Dr. Schaeffer to determine whether Quinn was still unable to work because of the cystitis. Dr. Schaeffer expressed his opinion that Quinn was not disabled in a telephone conversation with a Blue Cross nurse (BC 12(M) P50). In reliance on Dr. Schaeffer's statement and after an internal review of Quinn's claim by Blue Cross' Medical Director Dr. E. Richard Blonsky, Blue Cross sent Quinn a letter on September 19, 1995 stating that she did not have a disability as defined by the Program (BC 12(M) P53).

 Quinn appealed that decision to the Claims Appeals Committee ("Appeals Committee") in November 1995 and, after that appeal was denied, took her final appeal to the Secretary of the Benefits Committee in February 1996. As part of those appeals Quinn submitted evidence of additional medical evaluations that she had received from Dr. Pessis and from another treating urologist, Dr. Donald Hoard. Both of those physicians concurred that the physical pain and frequent need to urinate caused by Quinn's condition totally prevented her from working (Q. 12(N) P35). Quinn also submitted evidence that she had applied for and received disability benefits from the Social Security Administration ("SSA") during her appeals process (Q. 12(N) PP35, 36).

 Nonetheless Quinn's appeals were unsuccessful. First the Appeals Committee and then the Benefits Committee Secretary Dorothy Calhoon ("Calhoon") reviewed her file and decided against awarding her disability benefits. Quinn now challenges the final denial of her claim.

 Standard of Review

 Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115, 103 L. Ed. 2d 80, 109 S. Ct. 948 (1989) *fn3" has set out the definitive standards for judicial review of benefit eligibility and health plan interpretations:

 
Consistent with established principles of trust law, we hold that a denial of benefits challenged under § 1132(a)(1)(B) is to be reviewed under a de novo standard unless the benefit plan gives the plan administrator or fiduciary discretionary authority to ...

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