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Roque v. Roofers' Unions Welfare Trust Fund

United States District Court, Seventh Circuit

May 21, 2013

Steven Roque, Plaintiff,
v.
Roofers' Unions Welfare Trust Fund, Julia A. Rachal, and the Board of Trustees of the Roofers' Unions Welfare Trust Fund, Defendants.

MEMORANDUM OPINION AND ORDER

THOMAS M. DURKIN, District Judge.

Plaintiff Steven Roque brings this suit against Defendants Roofers' Unions Welfare Trust Fund ("Fund"), Julie Rachal, and the Board of Trustees of the Roofers' Unions Welfare Trust Fund ("Trustees"). The amended complaint sets forth a claim for benefits under § 502(a)(1)(B) of the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. § 1132(a)(1)(B) ("Count I"); requests that the Fund be estopped from denying coverage because it made knowing misrepresentations about Roque's coverage ("Count II"); and alleges a breach of fiduciary duty under ERISA § 502(a)(3), 29 U.S.C. § 1132(a)(3), against Rachal for failing to properly respond to participant inquiries ("Count III"), a breach of fiduciary duty under § 502(a)(3) against Rachal for failing to adequately train authorized representatives to properly respond to such inquiries ("Count IV"), and a breach of fiduciary duty against the Trustees for failing to properly monitor Rachal and Fund representatives ("Count V"). R. 25, Am. Compl. Defendants move to dismiss Counts II, III, IV, and V. R. 27. For the following reasons, defendants' motion to dismiss is granted. Counts II, III, IV, and V are dismissed. Only Count I of Roque's amended complaint remains.

Background

The following relevant facts, drawn from Roque's amended complaint, are accepted as true, and all reasonable inferences are drawn in his favor. See Tamayo v. Blagojevich, 526 F.3d 1074, 1081 (7th Cir. 2008). Roque is employed by M.W. Powell Company. R. 25 at § 7. As an employee of M.W. Powell Company, Roque was covered by the Fund pursuant to a collective bargaining agreement. Id. The Fund is an employee welfare benefit plan, and Roque, as an employee, received coverage under the Plan. Id. at § 8. Defendants Trustees and Rachal, as the Fund Manager, administered the Plan. Id. at §§ 9-12.

On March 19, 2001, Roque, while on the job as a roofer, fell through a roof and sustained injuries to his heel, pelvis, and back and Reflex Sympathetic Dystrophy Syndrome in his foot. Id. at § 14. As a result of his injuries, a spinal cord stimulator was inserted into his back on November 22, 2006. Id. at §§ 14, 16. Workers' compensation insurance covered Roque's medical expenses, including the cost of the procedure. Id. at §§ 15, 16. Roque settled his workers' compensation claim for $90, 000. Id. at § 19. The settlement agreement provided that Roque would assume all responsibility for any future medical expenses. Id. at § 21. In May 2011, Roque began experiencing pain in his foot. Id. at § 22. Dr. Vikram Patel, Roque's surgeon, advised him that the spinal cord stimulator may need to be repaired or replaced. Id.

The Plan and summary plan description ("SPD") describe the health benefits available under the Fund. R. 28, Exhs. A, B.[1] Both the Plan and SPD excluded coverage for treatment of injuries incurred while performing an act of employment where the benefits were payable by workers' compensation. The Plan provides:

No PLAN payment of any kind, except under the Loss of Life Benefit, will be made as a result of, or for charges incurred for the treatment of, any accidental bodily injury, sickness, or disease sustained while the individual was performing any act of employment or doing anything pertaining to any occupation or employment for remuneration or profit or for which benefits are or may be payable in whole or in part under any Workers' Compensation Law, Employer's Liability Law, Occupational Diseases Law, or similar law.

R. 28-2 at 13, Article 3.01.C.15 (emphasis in original). The SPD similarly provides:

Charges incurred or loss sustained in connection with, or as the result of, any accidental bodily injury, sickness or disease sustained while the Covered Person is performing any act of employment (including self-employment) or doing anything pertaining to any occupation, employment or activity, for remuneration or profit whether or not benefits are payable in whole or in part under any Workers' Compensation Law, Employer's Liability Law, Occupational Diseases Law or similar law.

R. 28-15 at 17. The SPD further advises participants: "If you have any questions about your benefits or your status under the Plan, contact the Fund Office at the address or telephone number shown on the inside of the front cover." R. 25 at § 31.

On June 3, 2011, Roque contacted the Fund Office to ask whether the Fund would cover the proposed procedure. Id. at § 23. Roque spoke with a Fund representative who gave him the telephone number of Med-Care Management ("Med-Care")-a third party contracted by the Fund to determine whether a procedure is covered under the terms of the Plan-and advised him to speak with Med-Care for answers to his questions. Id. at §§ 23, 33. Roque called the Fund Office again later that day. Id. at § 26. During that phone call, Roque told the Fund representative that: (1) he suffered a workplace injury in 2001; (2) the workers' compensation insurer covered the cost of the insertion of the spinal cord stimulator; (3) the workers' compensation case was closed with no open-ended settlement; and (4) the workers' compensation insurer would not pay for another spinal cord stimulator. Id. at § 27. The Fund representative informed Roque that the Fund Office did not confirm coverage for such a procedure, that Med-Care provides approval for procedures, and that Roque should follow up with Med-Care. Id. Following this phone call, Roque called Med-Care to confirm coverage for the proposed procedure. Id. at § 36. He provided the same information to Med-Care that he provided to the Fund Office in his second phone call, and Med-Care informed him that if workers' compensation denied the claim, the Plan would pay the claim. Id. at §§ 36-37.

On June 9, 2011, Med-Care issued a notification of authorization for outpatient admission for reflex sympathetic dystrophy of the lower limb, equipment failure, and replacement of the spinal cord stimulator. Id. at § 39; see also R. 25-5, Notification of Outpatient Admission. The notification was issued to Roque and his health service providers. Id. The notification further provided that "[t]his notification does not guarantee payment by the patient's medical plan. Payment is subject to the patient's eligibility and coverage limitations at the time services are delivered.... For confirmation of eligibility and benefits, please call the Fund Office." R-25-5. Roque's surgery was scheduled for June 28, 2011. R. 25 at § 41. After issuance of the authorization, Med-Care sent a copy of the pre-approval notice to the Fund Office, and on it, Med-Care notified the Fund Office that liability for the surgery may be completely or partially the responsibility of another insurer because of "an injury which may be covered by Workers' Compensation Insurance." Id. at § 40; see also R. 25-6. Between the June 9, 2011 receipt of the notification of the approval of the procedure and the June 28, 2011 surgery, the Fund Office did not contact Roque to advise him that the surgery may be excluded. R. 25 at § 43.

The surgery was performed on June 28, 2011. Id. at § 44. After the surgery, the Fund Office sent Roque Medical/Injury/Accident Information forms. Id. at § 49; R. 25-7, Exh. 7. Roque returned these forms, noting on them "Not a new accident. 2001' accident paid through. Comp. case is now closed, no open medical. They will not cover another spinal cord stimulator since case was settled in '07." R. 25-7. He also submitted a copy of the workers' compensation settlement. R. 25 at § 49.

On August 15, 2011, the Fund Office informed Roque that his claim was denied. Id. at § 50. On August 23, 2011, citing the exclusion from the SPD, the Plan reiterated it was not covering Roque's claim. Id. at §§ 51-52. Roque appealed the August 23, 2011 benefit denial, arguing that the Plan's exclusion was narrower than the SPD's exclusion, and that under the Plan's language, his claim was not excluded. Id. at § 54; see also R. 28-23, Exh. D. Following an appeals hearing before the Trustees, the Fund's Claim Review ...


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