Board of Trustees v. Kyle Moore

800 F.3d 214, 2015 FED App. 0207P, 60 Employee Benefits Cas. (BNA) 1569, 2015 U.S. App. LEXIS 14945, 2015 WL 5010985
CourtCourt of Appeals for the Sixth Circuit
DecidedAugust 25, 2015
Docket14-4048
StatusPublished
Cited by23 cases

This text of 800 F.3d 214 (Board of Trustees v. Kyle Moore) is published on Counsel Stack Legal Research, covering Court of Appeals for the Sixth Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Board of Trustees v. Kyle Moore, 800 F.3d 214, 2015 FED App. 0207P, 60 Employee Benefits Cas. (BNA) 1569, 2015 U.S. App. LEXIS 14945, 2015 WL 5010985 (6th Cir. 2015).

Opinion

OPINION

MARTHA CRAIG DAUGHTREY, Circuit Judge.

The subrogation claim in this case arose from a dispute over the Health Benefits Plan established by the Board of Trustees of the National Elevator Industry (NEI Board) under ERISA — the Employee Retirement Income Security Act of 1974, 29 U.S.C. §§ 1001-1461. The NEI Board, acting as the fiduciary and administrator of the Plan, sued Kyle Moore and the law firm Goodson & Company, Ltd. (collectively, “Moore”), seeking reimbursement for medical expenses that the Plan paid on Moore’s behalf, following Moore’s successful settlement of a negligence action filed against the entities responsible for injuries he suffered in an accident. In response, Moore contended that the terms of the Plan did not provide for reimbursement and filed a counterclaim alleging that the Board had violated its fiduciary duty by misrepresenting the terms of the Plan. Because the district court correctly concluded that the summary plan description containing the subrogation provision set out the binding terms of the Plan and that the plain language of the provision required reimbursement, we affirm. We also conclude that the district court’s limitation on the scope of discovery did not constitute an abuse of discretion.

FACTUAL AND PROCEDURAL BACKGROUND

The NEI Board administers a self-funded, multi-employer health plan covered by ERISA that provides health benefits to the employees of hundreds of companies in the elevator industry. Two documents related to the plan are at issue here. The first is titled Restated Agreement and Declaration of Trust (Trust Agreement), entered into in 1976 (and amended 17 times since then) by the participating elevator companies and the NEI Board. The Trust Agreement provides for the establishment and funding of the “The National Elevator Industry Health Benefit Plan” and sets out the method of selection, powers, and obligations of the NEI Board, which acts as both administrator and fiduciary of the trust.

As important as what the Trust Agreement does contain is what it does not: the customary nuts and bolts of an ERISA health plan. The document does not specify what claims and services are covered, the costs for which the participants and their beneficiaries are responsible, and how a participant may file a claim to secure benefits. Instead, Article YII of the Trust Agreement provides that “[t]he Trustees shall have full discretionary authority to adopt a Plan of Welfare Benefits, which sets forth eligibility requirements, type, amount, and duration of benefits that are to be provided to eligible employees.... ” Further, a paragraph titled Written Plan of Benefits provides that “[t]he detailed basis on which payment of benefits is to be made pursuant to this Trust Agreement shall be set forth in the Plan of Welfare Benefits ... [and] shall be subject to amendment by the Trustees from time to time.”

The second document is the National Elevator Industry Health Benefit Plan Summary Plan Description, or SPD. The SPD provides the details not included in the Trust Agreement — for example, the scope of eligibility for health benefits coverage and how the plan and participants divide medical expenses. The SPD also *217 includes a subrogation provision labeled Other Party Liability Claims:

The Plan has the right to recover benefits advanced by the Plan to a covered person for expenses or losses caused by another party. If a covered person is injured or becomes ill under circumstances where another party is directly or indirectly liable for the illness or injury, the Plan is only obligated to provide covered benefits resulting from that illness or injury that exceed any amounts recovered from another party (whether or not the amount recovered is designated to cover medical expenses).
Amounts that have been recovered by a covered person from another party are assets of the Plan by virtue of the Plan’s subrogation interest and are not distributable to any person or entity.... However, amounts recovered by such covered person from another party in excess of benefits paid by the Plan are the separate property of such covered person.
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The Plan has a right of first reimbursement out of any recovery. Acceptance of benefits from the Plan for an injury or illness by a covered person, without further action by the Plan and/or the covered person, constitutes an agreement that any amounts recovered from another' party by award, judgment, settlement or otherwise, and regardless of how the proceeds are characterized, will promptly be applied first to reimburse the Plan in full for benefits advanced by the Plan due to the injury or illness and without reduction for attorneys’ fees, costs, expenses or damages claimed by the covered person, and regardless of whether the covered person is made whole or recovers only part of his/her damages. ‡ ‡
The covered person agrees that neither he/she nor anyone acting on his/her behalf will settle any claim relating to the injury or illness without the written consent of the Plan.

Defendant Kyle Moore qualified as a beneficiary of the NEI Plan through his father, who was a plan participant. After Moore was injured in a 2007 car accident allegedly caused by a deputy sheriff, the plan paid $34,204.10 in medical expenses on his behalf. Moore, represented by the personal-injury firm Goodson & Company, filed a negligence action in state court against the deputy, the Hamilton County Sheriffs Department, and the County, seeking damages for his injuries that specifically included in detail the expenses already paid by the NEI Plan. As a partial defense to Moore’s claims, the state-court defendants relied on an Ohio collateral-source statute providing that benefits for an injury or loss received from a third-party source, including an insurance policy, be deducted from any award against a political subdivision for that injury. See Ohio Rev.Code § 2744.05(B)(1). The statute also provided that “[a] claimant whose benefits have been deducted from an award under ... this section is not considered fully compensated and shall not be required to reimburse a subrogated claim for [the deducted] benefits....” Id.

In order to protect its subrogation rights and to establish a lien against any recovery that Moore could receive for his medical expenses, the NEI Board intervened as a plaintiff in Moore’s state court action and filed a motion to strike the collateral-source defense as preempted by ERISA. Before that issue was resolved and before the case came to trial, Moore settled his claims against the state-court defendants for $500,000, without notice to the NEI Board. The settlement agreement *218 provided that the amount paid “represents the settlement of all of Moore’s claims but specifically excludes the payments for medical expenses made by National Elevator Industry Health Benefit Plan on his behalf____” Similarly, the sections of the agreement setting out Moore’s release and indemnity obligations exempted “the alleged subrogation claim of National Elevator Industry Health Benefit Plan....

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800 F.3d 214, 2015 FED App. 0207P, 60 Employee Benefits Cas. (BNA) 1569, 2015 U.S. App. LEXIS 14945, 2015 WL 5010985, Counsel Stack Legal Research, https://law.counselstack.com/opinion/board-of-trustees-v-kyle-moore-ca6-2015.