Debra Shaw v. The McFarland Clinic

CourtCourt of Appeals for the Eighth Circuit
DecidedApril 13, 2004
Docket02-3897
StatusPublished

This text of Debra Shaw v. The McFarland Clinic (Debra Shaw v. The McFarland Clinic) is published on Counsel Stack Legal Research, covering Court of Appeals for the Eighth Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Debra Shaw v. The McFarland Clinic, (8th Cir. 2004).

Opinion

United States Court of Appeals FOR THE EIGHTH CIRCUIT ___________

Nos. 02-3897 and 03-1167 ___________

Debra Shaw, * * Plaintiff-Appellee, * * Appeals from the United States v. * District Court for the * Southern District of Iowa. The McFarland Clinic, P.C., * * Defendant-Appellant. * ___________

Submitted: December 18, 2003

Filed: April 13, 2004 ___________

Before RILEY, LAY, and HEANEY, Circuit Judges. ___________

LAY, Circuit Judge.

Debra Shaw brought the present Employee Retirement Income Security Act of 1974 (“ERISA”) action against her employer seeking to recover benefits she alleged were due her under a health benefit plan. The district court1 granted summary judgment in favor of Shaw, and we affirm.

1 The Honorable Robert W. Pratt, United States District Judge for the Southern District of Iowa. I. BACKGROUND

Debra Shaw is Iowa’s last known polio victim. Shaw contracted the infectious disease at nineteen months of age in June of 1959, which inhibited the normal growth of the muscles in her left leg. At a young age, Shaw’s left calf muscle was so severely deformed and undersized that it was unable to support any weight, causing her to resort to the assistance of a full leg brace in order to walk. Throughout the course of her life, Shaw has undergone various medical procedures in an attempt to alleviate her condition, each with only limited success. Although she is presently able to walk unaided, Shaw’s balance and gait are still hampered, as her left leg is slightly shorter than her right. Shaw suffers from persistent physical pain in her knee, ankle, and lower back, due to the inability of her left calf to support significant weight. Shaw’s deformity also serves as a constant visual reminder of her affliction, resulting in considerable emotional distress.

Sometime in September of 1997, Shaw was seen in consultation by Dr. Marie E. Montag regarding the possibility of reconstructive plastic surgery on her left calf. Dr. Montag determined that a viable treatment option existed, known as tissue expander reconstruction surgery, which would add weight and definition to Shaw’s calf and thereby reduce her physical pain. Excited by the prospect of living a normal and healthy life, Shaw began the process of obtaining the preauthorization for the surgery from her employer, the McFarland Clinic, P.C. (“McFarland”).

McFarland is one of the largest multi-speciality clinics in Iowa, offering a wide array of healthcare services to residents of over thirty communities located in central Iowa. To provide its employees with healthcare coverage, McFarland sponsors the McFarland Clinic, P.C. Health Benefit Plan (the “Plan”), a self-funded health benefit plan covering any expenses incurred by both an employee and his or her dependents for medically necessary services. Before an employee undergoes any hospitalization or medical procedure, however, he or she first must obtain preauthorization from

-2- McFarland.2 According to the terms of the Plan, “[p]reauthorization allows [McFarland] to evaluate the medical appropriateness of services and provides [the employee] with assurance that the hospitalization or procedure is medically necessary and will be covered . . . .” Jt. App. at 121.

On September 24, 1997, Dr. Montag, on Shaw’s behalf, wrote to McFarland requesting preauthorization for tissue expander reconstruction surgery. On December 15, 1997, McFarland denied Shaw’s request on the basis that the requested procedure was “cosmetic surgery,” and therefore was not covered by the Plan. Over the next several months, Shaw and several other physicians wrote to McFarland, urging it to reconsider the denial of preauthorization. By letter dated January 9, 1998, Dr. Montag stated:

I do concede that placement of calf implants would indeed improve [Shaw’s] cosmetic appearance but this increased weight and volume of the affected leg would also improve her balance and thereby cause an improvement in her gait overall. Ms. Shaw has had problems with pain in the left ankle and knee as well. These are quite probably due to abnormal stresses on these areas due to her asymmetric balance and these symptoms also could be helped by placement of prosthetic implants.

Id. at 101.

On January 13, 1998, two of McFarland’s own physicians, Diane Cardwell, P.A., and Terry McGeeney, M.D., opined that the reconstructive surgery should be

2 As a purely technical matter, an employee submits a claim for preauthorization not to McFarland, but instead to Health Alliance Medical Plans (“HAMP”), a third- party plan administrator to whom McFarland has delegated a majority of its duties. Nevertheless, because McFarland is responsible for the actions of its agent, we refer to correspondence sent to, and actions taken by, HAMP as though McFarland was the primary actor.

-3- covered under the Plan, insofar as it provided coverage for “cosmetic implant[s] secondary to a medical condition,” id. at 102, such as breast implants following a mastectomy. On January 23, 1998, and again on April 2, 1998, Shaw made impassioned pleas for preauthorization. Each of these requests fell on deaf ears. On May 21, 1998, McFarland finally denied Shaw’s request for preauthorization, forcing Shaw to pay for the reconstructive surgery out of her own pocket.

On May 25, 2001, Shaw commenced the instant action under § 502(a)(1)(B) of ERISA, 29 U.S.C. § 1132(a)(1)(B), alleging that McFarland’s denial of preauthorization was an abuse of discretion insofar as tissue expander reconstruction surgery was covered under the terms of the Plan. In the alternative, Shaw’s complaint alleged that McFarland’s denial of preauthorization was a breach of its fiduciary duty owed to her as an individual beneficiary of the Plan. On cross-motions for summary judgment, the district court entered judgment in favor of Shaw. See Shaw v. McFarland Clinic, P.C., 231 F. Supp. 2d 924 (S.D. Iowa 2002). The district court found that McFarland abused its discretion as plan administrator in denying Shaw’s request for preauthorization, awarding her $10,979.00 plus interest accrued since May 21, 1998. The district court later awarded Shaw attorney fees and costs pursuant to 29 U.S.C. § 1132(g)(1).

On appeal, McFarland argues that the district court erred in awarding Shaw any relief, including attorney fees and costs, insofar as her action is barred by the statute of limitations.3

3 In its notice of appeal, McFarland also raised issues going to the merits of Shaw’s claim, arguing that the district court erred in finding that it had abused its discretion as plan administrator in denying Shaw’s claim for benefits. See Shaw, 231 F. Supp. 2d at 936-42. However, on appeal McFarland explicitly acknowledged that while it “continues to believe that [the issues going to the merits] present grounds for the reversal of the district court’s judgment, it has chosen not to pursue those issues.” Appellant’s Br. at 2. Even if McFarland had not made such an acknowledgment,

-4- II. ANALYSIS

The parties do not dispute that Shaw’s cause of action for abuse of discretion accrued on May 21, 1998, the date on which McFarland finally denied her request for preauthorization. See Union Pac. R.R. Co. v. Beckham, 138 F.3d 325, 330 (8th Cir. 1998) (“[T]he general rule in an ERISA action is that a cause of action accrues after a claim for benefits has been made and has been formally denied.”). Instead, the parties’ dispute on appeal focuses on whether Shaw commenced her action in a timely manner.

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Debra Shaw v. The McFarland Clinic, Counsel Stack Legal Research, https://law.counselstack.com/opinion/debra-shaw-v-the-mcfarland-clinic-ca8-2004.