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Sadowski v. Tuckpointers Local 52 Health & Welfare Trust

United States District Court, N.D. Illinois, Eastern Division

December 20, 2017

AMANDA SADOWSKI, Plaintiff,
v.
TUCKPOINTERS LOCAL 52 HEALTH & WELFARE TRUST, Defendant.

          MEMORANDUM OPINION AND ORDER

          Harry D. Leinenweber, Judge.

         Plaintiff Amanda Sadowski (“Sadowski”) brings this action against Defendant Tuckpointers Local 52 Health & Welfare Trust (the “Fund”) pursuant to § 1132(a)(1)(B) of the Employee Retirement Income Security Act of 1974 (“ERISA”), see 29 U.S.C. § 1001 et seq., alleging wrongful denial of medical benefits under the terms of her plan. Before the Court are Cross Motions for Summary Judgment [ECF Nos. 15, 24]. For the reasons stated herein, the Court grants Plaintiff's Motion for Summary Judgment and denies Defendant's Motion for Summary Judgment.

         I. FACTUAL BACKGROUND

         Sadowski brings this case under ERISA seeking payment for medical claims involving the removal of her spinal cord stimulator. Before discussing the claims at issue, the Court reviews her relevant medical history.

         A. Sadowski's Medical History

         About two years prior to the medical claims at issue here, Sadowski (about 27-years-old at the time) was seriously injured in a car accident when her vehicle was struck and pushed into a guardrail on April 30, 2013 (the “Car Accident”). (Def.'s Resp. to Pl.'s 56.1(a)(3) Statement, ECF No. 26 (“Def.'s 56.1 Resp.”) ¶¶ 1, 8.) Prior to the Car Accident, Sadowski was diagnosed with Complex Regional Pain Syndrome (“CRPS”) due to suffering from chronic pain during her teenage years, but she had been asymptomatic since age 18 or 19. (Pl.'s Resp. to Def.'s 56.1(b) Statement of Add'l Facts, ECF No. 29 (“Pl.'s 56.1 Resp.”) ¶¶ 6-7; Def.'s 56.1 Resp. ¶¶ 7, 9.) Along with other serious injuries, the Car Accident caused an occurrence of CRPS in the lower right part of her body. (Id.) After various treatments were ineffective, she underwent surgery, based on medical advice, to implant a spinal cord stimulator to treat the CRPS in the fall of 2013. (Def.'s 56.1 Resp. ¶¶ 13-14; Pl.'s 56.1 Resp. ¶ 8.) Her condition significantly improved after the implant of the spinal cord stimulator. (Def.'s 56.1 Resp. ¶ 14.) The Fund paid for all of the medical expenses associated with the Car Accident, including the implantation of the spinal cord stimulator. (Pl.'s 56.1 Resp. ¶ 9.)

         B. Previous Lawsuit and Settlement

         Sadowski, through her attorney, brought a personal injury lawsuit against third parties responsible for the Car Accident, which apparently resulted in a settlement. (See, Def.'s 56.1 Resp. ¶¶ 15-21.) The Fund and Sadowski agreed to settle the Fund's reimbursement lien for the medical bills paid by the Fund resulting from the Car Accident. (Id.)

         C. Relevant Portions of the Plan

         The Plan governing Sadowski's benefits contains provisions addressing the Fund's rights to reimbursement for medical expenses it paid in the event of third-party settlement or recovery:

Section 12.3 Settlement or Recovery
In the event of any recovery by judgment or settlement against the responsible party or parties, the reasonable cost of collection including attorney's fees shall first be deducted. The Fund's subrogation interests, to the full extent of benefits paid or due as a result of the occurrence causing the injury or illness, shall next be deducted. The Fund's subrogation interest will extend to all amounts recovered irrespective of how they are denominated in the settlement of judgment. The remainder or balance of any recovery shall then be paid to the Eligible Participant or Dependent.

(Plan Document (the “Plan”), Ex. A to Compl., ECF No. 1, § 12.3.) Relevant here, the Plan also provides for future medical expenses as follows:

Section 12.3 Settlement or Recovery
[. . .]
Once a settlement is reached, additional bills cannot be submitted with respect to the same injury.

         The Plan also has a summary plan description; however, the summary plan is silent about the exclusion of future medical expenses. (Pl.'s 56.1(a)(3) Statement, ECF No. 16 (“Pl.'s 56.1”) ¶ 79; Administrative Record (“AR”) at 1016.) Additionally, the Plan provides discretionary authority to the Plan Administrator in Section 13.1(a):

(2) Discretionary Authority of Plan Administrator and Designees
In carrying out their respective responsibilities under the Plan, the Fund Administrator, and other Plan fiduciaries and individuals to whom responsibility for the administration of the Plan has been delegated, have discretionary authority to interpret the terms of the Plan and to interpret any facts relevant to the determination, and to determine eligibility and entitlement to Plan Benefits in accordance with the terms of the Plan. Any interpretation or determination made under that discretionary authority will be given full force and effect, unless it can be shown that the interpretation or determination was arbitrary and capricious.

(See Plan, § 13.1(a); Pl.'s 56.1 Resp. ¶ 1; AR at 922.)

         D. ...


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