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Yolanda Bzdyk v. Sheet Metal Workers Local 265 Welfare Fund

August 22, 2011

YOLANDA BZDYK, PLAINTIFF,
v.
SHEET METAL WORKERS LOCAL 265 WELFARE FUND, DEFENDANT.



The opinion of the court was delivered by: Judge Robert M. Dow, Jr.

MEMORANDUM OPINION AND ORDER

This matter is before the Court on Defendant Sheet Metal Workers Local 265 Welfare Fund's ("Defendant" or "Fund") motion for summary judgment [11]. For the reasons stated below, the Court grants Defendant's motion [11].

I. Standard of Review

Plaintiff's claim is governed by the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. § 1001, et seq., which was "enacted to promote the interests of employees and their beneficiaries in employee benefit plans, and to protect contractually defined benefits." Black & Decker Disability Plan v. Nord, 538 U.S. 822, 829 (2003) (quoting Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 113 (1989)). The statute permits a person who is denied benefits under an ERISA employee benefit plan to challenge that denial in federal court. Metropolitan Life Ins. Co. v. Glenn, 554 U.S. 105, 108 (2008); see also 29 U.S.C. § 1132(a)(1)(B). In moving for summary judgment, Defendant asks the Court to determine the question of Plaintiff's eligibility for certain benefits based on the Fund's Health and Welfare Plan, Plaintiff's medical records, the Fund's initial decision and decision on appeal, and the deposition of Dr. Loftin, one of the medical consultants employed by the Fund who reviewed Plaintiff's eligibility for benefits. Generally, "[t]he standard of review of a Plan Administrator's decisions regarding benefits depends on whether the Plan Administrator was given the discretion to make those decisions." Vallone v. CNA Fin. Corp., 375 F.3d 623, 629 (7th Cir. 2004). The Supreme Court has held 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 administrator or fiduciary discretionary authority to determine eligibility for benefits or to construe the terms of the plan." Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989). Both sides agree that the appropriate standard for the Court's review of Defendant's benefits determination is whether the plan administrator's decision was arbitrary and capricious.

II. Facts

The Welfare Fund is a joint labor-management trust fund established pursuant to collective bargaining for the purpose of providing welfare benefits to persons employed under various collective bargaining agreements. The Welfare Fund is administered by a Board of Trustees, employs a staff of people to perform services to accomplish the Fund's objectives, and maintains an office for the conduct of regular business operations in Carol Stream, Illinois.

The principal document governing the operation of the Welfare Fund is the Health and Welfare Plan, as from time to time amended. At all relevant times, the Health and Welfare Plan has contained certain provisions governing the administration of the Fund. Specifically, the Plan provides that:

Only the Board of Trustees has the authority to determine eligibility for benefits and the right to participate in the Plan and to exercise all the other powers specified in the Plan. The Trustees may, in their sole and broad discretion, modify, amend, or terminate the Plan in any matter or at any time. No officer, agent, or employee of the Union or Employer or any other person, is authorized to speak for, or on behalf of, or to commit the Board of Trustees, on any matter relating to the Health and Welfare Fund or Plan.

The Trustees also decide any factual question related to eligibility for and the type and amount of benefits. The decision of the Trustees is final and binding and will receive judicial deference to the extent that it does not constitute an abuse of discretion. If a decision of the Trustees is challenged in court, the decision will be upheld unless the court finds that it is arbitrary and capricious.

The Welfare Plan identifies the Board of Trustees of the Welfare Plan as both the Plan Sponsor and Plan Administrator.

On or about February 1, 2008, Plaintiff Yolanda Bzdyk, a participant in the fund, had an office visit with her reproductive specialist, Dr. Zvi Binor, at Rush-Copley Center for Reproductive Health. Plaintiff's medical records demonstrate a long-standing history of fertility-related issues. Between February 2008 and May 2008, Plaintiff and her husband visited Rush-Copley for various fertility-related tests. Then, on July 18, 2008, she underwent a diagnostic laparoscopy, during which Dr. Zvi Binor excised lesions and removed ovarian cysts. The "Report of Operation" noted that endometriosis appeared in the bladder flap and that pelvic endometriosis was identified on the ovary. The report also states that "[f]ollowing the lavage of the pelvis and fulguration of the endometriosis, the procedure was terminated." Plaintiff's medical records from July 18, 2008, state that she has "a history of endometriosis in the pelvis with adhesions." The records also indicate that she "underwent 2006 laparoscopy/hysteroscopy for endometriosis, lysis of adhesions on the left adnexa, removal of left tubal cyst, and small uterine fibroids as well." Plaintiff also complained of abdominal pain (which can be caused by pelvic adhesions and endometriosis) in the pelvis prior to July 18, 2008. In her statement of facts, Plaintiff admits that the surgery performed on July 18, 2008, would not have been performed in the absence of infertility. Pl.'s SOF ¶ 24.

Upon receipt of the claims for these visits, the Fund Office sent the claims to a medical consultant to determine whether the services were related to infertility.*fn1 The medical consultant found the services related to the treatment of infertility. Based upon the medical consultant's opinion, the Fund Office denied the claims because the participant's infertility treatment benefits maximum had already been exhausted. The Sheet Metal Workers Local 265 Health and Welfare Summary Plan Description includes a summary of benefits chart which provides that the Plan limits major medical benefits benefits for infertility treatment to $25,000 per family per lifetime. Major Medical Covered Expenses include: "For Class A, E, G, H, and I Eligible Employees and Dependent Spouses only, infertility treatment, up to the Plan's limits, for office visits, x-ray and lab, prescription drugs, drug/hormone therapy, and Surgical Procedures for infertility."

On March 10, 2009, Plaintiff's husband, Mark Bzdyk, wrote a letter to the Fund stating that the treatment at issue was for endometriosis, a gynecological condition. Mr. Bzdyk also enclosed a letter from Plaintiff's physician, Dr. Binor Zvi, which stated that Plaintiff had presented in his office with "increasing pelvic pain symptoms" and that the procedure was done to treat endometriosis. The letter also stated that "[w]hile the procedure can improve her overall fertility, it was done to treat endometriosis, which as you know, is a gynecological condition." Upon receipt of Mr. Bzdyk's appeal, the Fund Office sent the claims and relevant documentation to a second medical consultant, Dr. Eugene Loftin, to determine whether the services were related to the treatment of infertility. Dr. Loftin concluded, "Based on the information received, review of the scientific evidence, other outside authority, and my own experience, the treatment/charges are all infertility related."

During his deposition, Dr. Loftin stated that he was aware that Dr. Binor had said that the "patient has some pelvic pain as well," but Dr. Loftin was of the opinion that the pain was "hardly the reason she presented." He also testified that he is familiar with endometriosis, pelvic adhesions, and laparoscopic procedures, and he further testified that if endometriosis "is severe enough" or if pelvic adhesions need treatment, a laparoscopic procedure could be performed. Specifically, he agreed that if a doctor suspects or has a patient that has severe endometriosis or severe pelvic adhesions, a laparoscopy would be appropriate for diagnostic purposes and special tools would be used to address problems identified. He also agreed that if a patient "presented with primary complaint of pain unrelieved by conservative medical management and she goes to her regular gynecologist, this would be something we would consider medical/surgical treatment." Finally, he testified that laparoscopy can cauterize or burn out endometriosis.

On May 7, 2009, the Board of Trustees considered Mr. Bzdyk's appeal and the Fund's file on the claims at issue. Based on the two independent medical consultants' opinions that the treatment at issue was related to infertility, and that Ms. Bzdyk has already exhausted the Plan's available benefits, the Board of Trustees upheld the administrative manager's denial of the claims and explained the reasoning in a ...


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