Deville Nursing Service, Inc. v. Metropolitan Life Insurance

789 F. Supp. 213, 1992 U.S. Dist. LEXIS 5572, 1992 WL 82177
CourtDistrict Court, W.D. Louisiana
DecidedApril 14, 1992
DocketCiv. A. No. 90-0707
StatusPublished
Cited by1 cases

This text of 789 F. Supp. 213 (Deville Nursing Service, Inc. v. Metropolitan Life Insurance) is published on Counsel Stack Legal Research, covering District Court, W.D. Louisiana primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Deville Nursing Service, Inc. v. Metropolitan Life Insurance, 789 F. Supp. 213, 1992 U.S. Dist. LEXIS 5572, 1992 WL 82177 (W.D. La. 1992).

Opinion

MEMORANDUM RULING GRANTING MOTION FOR SUMMARY JUDGMENT

EDWIN F. HUNTER, Jr., Senior District Judge.

Pending for determination is a Motion for Summary Judgment filed by defendants, Chevron Corporation Medical Plan and Chevron Corporation Medical Plan Organization. In a letter of April 8, 1992, plaintiff states that they have no response to the Motion for Summary Judgment, except to state that, based upon the evidence submitted with defendants’ Motion, there is a genuine issue of material fact and should therefore be denied. For the below reasons, the Motion is granted.

FACTS

The following statement of uncontested material facts is correct.

1. Chevron Corporation Medical Plan (the “Plan”) was established by Chevron Corporation (“Chevron”) to provide health care benefits to employees and eligible retirees who elect to participate in the Plan and to their covered dependents.
2. The Plan is administered and maintained pursuant to the Employee Retirement Income Security Act of 1974, 29 U.S.C. Section 1001 et seq. (“ERISA”).
3. The Plan is not insured but is funded by Chevron and Chevron employee contributions.
4. Metropolitan Life Insurance Company (“Metropolitan”) is the Claims Administrator for the Plan.
5. As Claims Administrator, Metropolitan is responsible for the initial process and review of claims under the Plan but does not insure the benefits paid.
6. Under the Plan, Chevron Corporation Medical Plan Organization (the “Organization”) is the designated Plan Administrator and, as such, has full, exclusive and discretionary authority to control and manage the administration and operation of the Plan and to construe the terms of the Plan and determine all issues relating to coverage and eligibility for benefits.
7. In carrying out its responsibilities, the Organization has delegated to a Review Panel the full discretionary authority to determine benefit eligibility and interpret Plan provisions with respect to any appeal from a denial of benefits under the Plan, including a denial of benefits by the Plan’s Claims Administrator, Metropolitan.
8. All decisions rendered by the Review Panel regarding appealed claims are deemed final and binding upon all persons, including the Organization as Plan Administrator.
9. Beginning on February 15, 1989, and continuing through March 28, 1989, William F. Martin (“Mr. Martin”), a former employee and a Plan participant, received in-home nursing services from Deville Nursing Service, Inc. (“Deville”).
10. Claims for payment for Deville’s services were made to Metropolitan, the Plan’s Claims Administrator.-
11. Upon receiving and reviewing nursing notes submitted by Deville documenting the services rendered Mr. Martin between February 15, 1989 and March 20, 1989, and letters submitted by Mr. Martin’s treating physician, Dr. Alexandre L. Slatkin, Metropolitan determined that the services rendered by Deville were not medically necessary nursing services for [215]*215the treatment of a sickness or injury performance by skilled nurses only. Rather, Metropolitan concluded that the services provided to Mr. Martin were custodial in nature and therefore excluded under the specific terms and conditions of the Plan.
12. Deville, as assignee of Mr. Martin’s rights under the Plan, brought suit against the Plan and the Organization, alleging that the denial of Mr. Martin’s benefits and the refusal by the Plan to pay Deville for services rendered from February 15, 1989 through March 20, 1989 was “arbitrary and capricious, and unsupported by substantial evidence and founded on an erroneous interpretation of the law and the Plan, itself.”
13.. Deville was subsequently notified that a Review Panel was being appointed by the Organization for the purpose of reviewing the denied claim.
14.The Review Panel appointed to consider the appeal of the claim included a medical doctor on Chevron’s Medical Staff and two (2) Chevron Human Resources Department employees.
15. Deville was given an opportunity to submit additional information or documentation that it considered helpful in assigning the Review Panel in making its review.
16. Deville submitted as additional information a transcript of the deposition of Dr. Alexandre L. Slatkin, Mr. Martin’s treating physician, whose deposition was taken on September 13, 1991.
17. Upon reviewing the nurses’s notes, Dr. Slatkin’s letters, Dr. Slatkin’s deposition testimony, as well as other documentation and other correspondence, the Review Panel, on or about October 18,1991, rendered its decision, affirming Metropolitan’s denial of Mr. Martin’s (and De-ville’s) claim for benefits.
18. On October 23, 1991, the Organization, as Plan Administrator, notified De-ville (and Mr. Martin) of the Review Panel’s decision.

LAW AND ARGUMENT

ERISA comprehensively regulates employee welfare benefit plans that provide benefits in the event of sickness or disability. It preempts state laws regulating the processing of claims for benefits under ERISA-regulated benefit plans. 29 U.S.C. § 1001(b); Pilot Life Insurance Co. v. Dedeaux, 481 U.S. 41, 107 S.Ct. 1549, 95 L.Ed.2d 39 (1987).

The appropriate standard of judicial review regarding actions challenging a denial of benefits under an ERISA plan is defined in Firestone Tire and Rubber Company v. Bruch, 489 U.S. 101, 109 S.Ct. 948, 103 L.Ed.2d 80 (1989).

Noting that “ERISA abounds with the language and terminology of trust law,” the Supreme Court held that if the “... benefit plan gives the administrator or fiduciary discretionary authority to determine eligibility for benefits or to construe the terms of the plan,” judicial review shall be limited to the more deferential “abuse of discretion” standard. Id. at 110-115, 109 S.Ct. at 954-56. See also Morales v. Pan Am. Life Ins. Co., 914 F.2d 83, 87-88 (5th Cir.1990).

The plan here gives the administrator or fiduciary full discretionary authority to determine eligibility for benefits. Specifically, Sections 11(b), 14(a) and (e) of the Plan provide:

Section 11. Administration and Operation of the Plan
(b) Administration Power and Responsibility. The Organization is the named fiduciary that has the authority to control and manage the administration and operation of the Plan. The Organization shall prescribe such forms, make such rules, regulations, interpretations and computations and shall take such other action to administer the Plan as it may deem appropriate....

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789 F. Supp. 213, 1992 U.S. Dist. LEXIS 5572, 1992 WL 82177, Counsel Stack Legal Research, https://law.counselstack.com/opinion/deville-nursing-service-inc-v-metropolitan-life-insurance-lawd-1992.