Custer v. Pan American Life Insurance

12 F.3d 410
CourtCourt of Appeals for the Fourth Circuit
DecidedDecember 17, 1993
DocketNo. 92-2570
StatusPublished
Cited by3 cases

This text of 12 F.3d 410 (Custer v. Pan American Life Insurance) is published on Counsel Stack Legal Research, covering Court of Appeals for the Fourth Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Custer v. Pan American Life Insurance, 12 F.3d 410 (4th Cir. 1993).

Opinion

OPINION

NIEMEYER, Circuit Judge:

Kimberly A. Custer sued Pan American Life Insurance Company and National Insurance Services, Inc., the providers to Custer’s employer of a group health insurance policy for the benefit of Custer and her fellow employees, claiming that Pan American Life and National Insurance .wrongfully denied her health benefits. In particular, she alleged that they wrongfully refused to cover expenses for a cesarean section operation and to provide benefits to her son who was born with spina bifida and hydrocephalus. The district court, deciding the claim under the Employee Retirement Income Security Act (ERISA), 29 U.S.C. § 1001, et seq., entered summary judgment in favor of the defendants, concluding that the defendants did pay all claimable benefits until' the date when the policy was terminated by Custer’s employer, and that they are not required to provide benefits beyond the termination of the policy, as argued .by Custer. Having fully considered all of the arguments raised on appeal, we affirm.

I

Kimberly Auber Custer was a beneficiary of a group health and life policy provided by her employer, Ohio Valley Candy Company. Ohio Valley Candy was a small, closely-held company, and Custer’s father, John Auber, [414]*414was its president. Auber arranged for the policy through James Arritt, the company’s insurance broker, who obtained the policy from National Insurance as administrator, and Pan American Life as underwriter. National Insurance is a wholly owned subsidiary of Pan American Life. The policy afforded no maternity benefits and did not cover preexisting conditions. .It did, however, afford coverage to newly born family members without proof of medical eligibility, so long as written notice of the child’s birth was provided within 31 days of the birth.

Before subscribing to the group policy, Custer became pregnant, and she so notified National Insurance at the time she subscribed. Toward the end of her pregnancy, it became apparent that a cesarean section would be required to deliver the baby. According to Custer, she advised Arritt of this fact, and Arritt told her that expenses for the surgery would be covered by the policy.

. On October 21, 1988, Custer gave birth to a son, Marc Custer. Marc was born with spina bifida and hydrocephalus, conditions which require continuous and expensive medical attention. Arritt notified National Insurance of Marc’s birth, orally and by two letters, for the purpose of triggering coverage without proof of eligibility. For some unexplained reason, the first letter dated November 11, 1988, was not received by National Insurance until March 27, 1989. When Ar-ritt inquired about the letter in late November 1988 and learned that it had not been received, he sent a follow-up letter, dated December 2, 1988. All parties agree that this second letter was received on December 5. Asserting that both letters were received after the 31-day grace period following Marc’s birth and that no proof of medical eligibility was submitted, National Insurance denied medical benefits to Marc. Medical benefits were also denied to Custer for her pregnancy, including coverage for the cesarean section.

Custer filed suit against National Insurance and Pan American Life in state court, claiming coverage for herself on the basis of the oral assurances given by Arritt, and for Marc, alleging that National Insurance did receive actual notice of his birth within 31 days. The state law claims were based on West Virginia common law and statute.

Shortly after Custer filed suit and before the defendants responded, Ohio Valley Candy canceled its policy with National Insurance and Pan American Life. Custer claims that John Auber canceled the policy because of his frustration with the way National Insurance and Pan American Life administered the policy. After the cancellation, the defendants admitted liability for benefits for Marc up to the date of cancellation and paid them.

The defendants removed the state court action to federal court, alleging that ERISA preempted the claims, and once in federal court, they filed a motion for summary judgment. They asserted that they had paid all obligations incurred for Marc up to the date of the cancellation and should not be held responsible for expenses incurred after cancellation. They also argued that the policy clearly excludes Custer’s childbirth expenses and that under ERISA, Arritt’s oral representation about coverage could not be enforced as a modification to the written policy. The district court did not rule on the merits of these claims but dismissed the complaint, reasoning that the plaintiffs state law claims were preempted by ERISA. The district court, however, granted plaintiff 30 days in which to file an amended complaint.

In her amended complaint, Custer abandoned her claims for maternity benefits but pursued claims on behalf of Marc for future benefits, even though the policy under which the claims were made had been canceled by her employer. She alleged that the defendants wrongfully interfered with her attainment of future rights in violation of 29 U.S.C. § 1140; that because the defendants knew that the denial of Mare’s claim was wrongful, they should be equitably estopped from relying on the cancellation of the policy; and that they had constructively terminated the policy before her employer’s cancellation by refusing to cover Mare. Even though Custer received some of the same benefits from her husband’s insurance company that she was claiming from National Insurance and Pan American Life, she argued also that the coordination of benefits clause in the policy with [415]*415National Insurance and Pan American Life did not apply to prevent double payment.

After the parties filed status reports in the litigation, the court entered an order directing the defendants to file their motion for summary judgment by July 31, 1992, which they said they intended to file, and ordering the plaintiff to respond in accordance with Local Rule 2.07. On July 14, 1992, the defendants filed a paper entitled, “Memorandum of Law in Support of Defendant’s Motion for Summary Judgment,” and in the memorandum they claimed entitlement to summary judgment on all counts. The defendants did not, however, file a separate paper making a formal motion for summary judgment. Custer filed no response to-, this “memorandum.” Several months later, on October 7,1992, the defendants filed a formal motion for the entry of summary judgment under Local Rule 2.07 on the basis that no response had been filed to their earlier paper. Again, Custer filed no response. On November 12, 1992, over a month later, the district court entered summary judgment for the defendants, relying both on Custer’s failure to comply with Local Rule 2.07 and on the merits of the defendants’ position. On the merits, the court concluded that the defendants had made all payments required by the policy before it was terminated and that they were not required to provide benefits beyond termination. The court also denied Custer attorney’s fees and refused to disregard the coordination of benefits provision within the policy. This appeal followed.

II

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12 F.3d 410, Counsel Stack Legal Research, https://law.counselstack.com/opinion/custer-v-pan-american-life-insurance-ca4-1993.