Debra Shaw v. The McFarland Clinic, P.C.

363 F.3d 744

• Court: Court of Appeals for the Eighth Circuit
• Decided: June 1, 2004
• Docket: 02-3897, 03-1167
• Status: Published

Opinions

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. • ,

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 McFarland.² According to the terms of the Plan, “[pjreauthorization 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 preau-thorization. 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 covered under the Plan, insofar as it provided coverage for “cosmetic implantfs] 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 preau-thorization 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

ÍI. 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’ disputé on appeal focuses' on Whether Shaw commenced her action in a timely manner. ' Since ERISA does not contain its own statute of limitations governing actions to recover benefits, we must look to Iowa law and borrow the most analogous statute of limitations. See Johnson v. State Mut. Life Assurance Co. of Am., 942 F.2d 1260, 1262 (8th Cir.1991). Because it arises out of an agreement entered into with McFarland, Shaw’s action is most analogous to a cause of action for breach of contract. See Adamson v. Armco, Inc., 44 F.3d 650, 652 (8th Cir.1995) (“At least in this circuit, it is settled that a claim for ERISA benefits is characterized as . a contract action for statute of limitations purposes.”).⁴

The present difficulty arises from the fact that Iowa law provides two separate statutes of limitation applicable to a contract action, one general and the other specific. As a general matter, a claim brought under ERISA relating to a contract of insurance is governed by a ten-year statute of limitations. See Iowa Code § 614.1(5); see also Hamm v. Allied Mut. Ins. Co., 612 N.W.2d 775, 783-84 (Iowa 2000). If, however, the contract arises out of an employment relationship and an employee seeks to recover wages from her employer, it is subject to a two-year statute of limitations. See Iowa Code § 614.1(8).

In determining which of these two periods of limitation to apply, we may inquire as to how Iowa law would characterize Shaw’s action. See Johnson, 942 F.2d at 1262; cf. United Auto. Workers v. Hoosier Cardinal Corp., 383 U.S. 696, 706, 86 S.Ct. 1107, 16 L.Ed.2d 192 (1966) (noting that “there is no reason to reject the characterization that state law would impose unless [it] is unreasonable or otherwise inconsistent with national labor policy”). According to McFarland, Shaw’s action is one that Iowa law would treat as an action for wages under the Iowa Wage Payment Collection Act (“IWPCA”), Iowa Code § 91A et seq., and is therefore subject to a two-year statute of limitations under Iowa Code § 614.1(8). Because Shaw filed suit on May 25, 2001, three years after her cause of action accrued, McFarland asserts that it is time-barred.

Since its enactment, Iowa courts have repeatedly stated that the purpose of the IWPCA is “to facilitate the public policy of allowing employees to collect wages owed to them by their employers.” Hornby v. State, 559 N.W.2d 23, 26 (Iowa 1997). Toward this end, and taking into consideration the highly evolving nature of employee compensation, the IWPCA sets forth an expansive definition of “wages,” encompassing much more than the regularly-issued paycheck. The IWPCA provides in relevant part:

“Wages” means compensation owed by an employer for:

c. Ahy payments to the employee or to a fund for the benefit of the employee, including but not limited to payments for medical, health, hospital, welfare, pension, or profit-sharing, which are due an employee under an agreement with the employer or under a policy of the employer. The assets of an employee in a fund for the benefit of the employee, whether such assets were originally paid into the fund by an employer or employee, are not wages.

d. Expenses incurred and recoverable under a health benefit plan.

Iowa Code § 91A.2(7)(c) and (d). If the benefits Shaw presently seeks to recover may be said to fit comfortably within one of these two statutory definitions of wages, McFarland would be correct to assert that Shaw’s action is time-barred. We believe, however, that neither definition is applicable under the facts presented on appeal.⁵

Section 91A.2(7)(c), by its. plain- language, is inapplicable to Shaw’s - action. The benefits that she seeks to recover do not constitute “payments to the employee,” because even assuming that McFarland had granted preauthorization,1 any payment for Shaw’s medical expenses would have been made directly to her healthcare provider.⁶ In addition, the benefits do not constitute payments to a “fund for -the benefit of the employee.” We submit that this reference was meant, to encompass only those funds in which the employee could be said to have an interest separate and distinct from other employees, i.e., a fund1 for retirement, pension, or profit-sharing. See, e.g., Phipps v. IASD Health Servs. Corp., 558 N.W.2d 198 (Iowa 1997) (holding that an employee’s individual share in the revenue of a company, due under a policy of the employer, constituted wages within the meaning of § 91A.2(7)(c)). In this case, there is no evidence that McFarland maintained individual healthcare funds for each of its employees that could be drawn upon by that employee. Finally, § 91A.2(7)(c) does npt apply because § 91A.2(7)(d) sets forth a definition of wages specifically addressing the type of benefit McFarland claims to be at issue: compensation due under the terms of a “health benefit plan.”⁷ See HCSC-Laundry v. United States, 450 U.S. 1, 6, 101 S.Ct. 836, 67 L.Ed.2d 1 (1981) (noting that “it is a basic principle of statutory construction that a specific statute ... controls over a general provision ..., particularly-when the two are interrelated and closely positioned”).

McFarland also claims that-Shaw’s action is one for wages, as that term is defined in § 91A.2(7)(d). This presents a closer question., Although § 91A.2(7)(d) defines wages as “[ejxpenses incurred and recoverable under a health benefit plan,” this definition is - similarly inapplicable to the present case. Like the district court, we believe the IWPCA only treats as wages those “[ejxpenses by the employee which are authorized by the employer and incurred by the employee.” Iowa Code § 91A.3(6) (emphasis added). Thus, for a medical expense to constitute wages within the meaning of § 91A.2(7)(d), it must be one that the employee has been authorized by her employer to incur. See Shaw, 231 F.Supp.2d at 934 (“Thus, expenses under a health benefit plan are not wages unless they are both incurred and recoverable[,] ie. [,] authorized and incurred.”). This is not true here, as McFarland explicitly refused to grant preauthorization for Shaw’s surgery.⁸ ■

In short, because Shaw’s claim against McFarland does not fit within either of the aforementioned definitions of wages, she has no cause of action under the IWPCA. This being the case, its two-year statute of limitations is inapplicable to limit her ERISA cause of action. Instead, Shaw’s action against McFarland “most closely resembles an insured party’s claim against his insurer for denial of coverage and breach of contract,” id., and is governed by a ten-year statute of limitations. This result is consistent with the general principle of Iowa law that when a court has to choose between competing statutes of limitation, any doubt as to which to apply “will generally be resolved in favor of the application of the statute containing the longest limitation.” Halverson v. Lincoln Commodities, Inc., 297 N.W.2d 518, 522 (Iowa 1980) (internal citation and quotation omitted). _ ■

Finally, we note that McFarland has not appealed the district court’s award of damages to Shaw nor its finding that McFarland abused its discretion by denying preauthorization. See supra n. 3. Thus, these issues are not presented for our review. Our holding that Shaw’s action is not time-barred disposes of McFarland’s claim that Shaw was not entitled to costs and attorney fees, as McFarland’s argument to the contrary was premised upon its view that Shaw’s action was untimely. Furthermore, our affirmance of the district court on Shaw’s abuse of discretion theory makes it unnecessary for us to reach the issue of her recovery on an alternative theory of breach of fiduciary duty. Nevertheless, to the extent the district court’s award of damages may have alternatively been premised on its determination that McFarland acted in bad faith and breached a fiduciary duty owed to Shaw, we part company with the district court. Needless to say, the Supreme Court has made clear that an individual generally may not recover monetary damages based upon a plan administrator’s breach of fiduciary duty, see. Mass. Mut. Life Ins. Co. v. Russell, 473 U.S. 134, 144, 105 S.Ct. 3085, 87 L.Ed.2d 96 (1985) (“[T]he entire text of [§ 1109] persuades us that Congress did not intend that section to authorize any relief except for the plan itself.”), especially when another enforcement provision of ERISA provides an adequate remedy. See Varity Corp. v. Howe, 516 U.S. 489, 515, 116 S.Ct. 1065, 134 L.Ed.2d 130 (1996).

III. CONCLUSION

Based on the foregoing, we hold that an employee’s action alleging the improper denial of preauthorization for health benefits by her employer is most analogous under Iowa law to an action for breach of a written contract. Because Shaw instituted the present action against McFarland well within the applicable ten-year statute of limitations, the judgment of the district court is AFFIRMED.

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

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 . 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, however, we doubt whether the claim would have been properly presented for our review. See Hays v. Hoffman, 325 F.3d 982, 986 n. 2 (8th Cir.2003) (noting that issues neither argued in a brief nor stated in its statement of issues are not preserved for appellate review).

4 . In all due respect, the dissent is misleading. The dissent argues that simply because "Shaw clearly has not alleged or argued an ordinary breach of contract action,” post, at 12, the Iowa statute of limitations for' a breach of contract is inapplicable. We respectfully disagree. As we have already stated, since ERISA does not contain its own statute of limitations, we must borrow the most analogous statute of limitations from Iowa law. Our discussion regarding breach of contract is directly relevant to this task. The dissent also overrides Iowa law, which we have cited, see post, at 10, that when a court has to choose between competing statutes of limitation, any doubt will be resolved in favor of the statute containing the longer period.

5 . The dissent basically adopts McFarland's argument on appeal. However, as the district court succinctly observed: "Although McFarland's argument is persuasive at first glance, it fails under close scrutiny.” Shaw, 231 F.Supp.2d at 933. The same may be said about the dissent.

6 . McFarland and the dissent argue that our decision in Mead v. Intermec Technologies Corp., 271 F.3d 715 (8th Cir.2001), stands for the proposition that the most analogous statute of limitations for actions brought under 29 U.S.C. § 1132(a)(1)(B) is always the two-year period prescribed in Iowa Code § 614.1(8). We respectfully submit Mead did not announce the broad proposition that McFarland and the dissent now propose. Rather, Mead held only that an employee’s claim for short-term disability payments was one for wages under the IWECA, and therefore governed by a two-year statute of limitations. Unlike the benefits presently at issue, short-term disability benefits are paid directly to the employee claiming entitlement to them, and therefore fit easily within the definition of wages provided in § 91A.2(7)(c). See also Hornby, 559 N.W.2d at 26 (holding that payments made directly to an employee for long-term disability benefits are wages within the meaning of § 91A.2(7)(c)).

It is also important to note that Mead was decided on several alternate grounds. First, it was determined that Mead was not eligible for short-term disability benefits. Mead, 271 F.3d at 717. Second, when Mead left the company, he entered into a severance agreement in which he waived all existing claims against the company. Id. Our statement that Mead's action was barred by the IWPCA's statute of limitations was clearly an afterthought, and. we gave no reasons for this interpretation of the IWPCA. Indeed, our entire analysis of the issue consisted of the following: "The District Court found that Mead’s claim fell within the Iowa Wage Payment Collection Act and was barred by the two-year statute of limitations. We agree.” Id. (citation omitted).

The dissent also refers to this court’s opinion in Adamson. We do not believe that Adamson is controlling. First, Adamson involved Minnesota, not Iowa, law; and second, it did not involve a question of whether an individual employee was entitled to a specific benefit under the plan. Rather, Adamson dealt with the termination of a benefit plan that affected all employees, a question clearly covered by the terms of the Minnesota wage statute.

7 . The IWPCA further defines a "health benefit plan” as "a plan or agreement provided by an employer for employees for the provision of or payment for care and treatment of sickness or injury.” Iowa Code § 91A.2(5).

8 . The dissent reasons that this reading "renders section 91A.2(7)(d) virtually meaningless,” post, at 14. The dissent somehow construes our holding that an employee such as Shaw has no cause of action under the IWP-CA as working some disadvantage to her. Not true. As the result we reach demonstrates, an employee could do exactly what Shaw attempts to do in this action — bring an ERISA action against the plan administrator for failure to grant preauthorization for a medical procedure. Such an action would be most analogous to one alleging a breach of contract, and thus governed by the ten-year statute of limitations. Furthermore, the dissent's argument concerning the breadth of the IWPCA’s coverage of healthcare expenses is best-suited for the Iowa legislature, not this court. See City of New Orleans v. Dukes, 427 U.S. 297, 303, 96 S.Ct. 2513, 49 L.Ed.2d 511 (1976) ("In short, the judiciary may not sit as a superlegislature to judge the wisdom or desirability of legislative policy determinations made in areas that neither affect fundamental rights nor proceed along suspect lines ....”). The plain language and overall scheme of the IWPCA evinces an intent on the part of the Iowa legislature to address only expenses that are authorized by an employer. See Iowa Code § 91A.3(6) (providing for reimbursement of expenses that are "authorized by the employer”); id. § 91A.7 (addressing disputes concerning the amount of "expense reimbursement due”); id. § 91A.8 (permitting the recovery of damages for failure to "reimburse expenses pursuant to section 91A.3”).