Evans v. W.E.A. Insurance Trust

361 N.W.2d 630, 122 Wis. 2d 1, 1985 Wisc. LEXIS 2107
CourtWisconsin Supreme Court
DecidedJanuary 31, 1985
Docket83-817, 83-1061
StatusPublished
Cited by9 cases

This text of 361 N.W.2d 630 (Evans v. W.E.A. Insurance Trust) is published on Counsel Stack Legal Research, covering Wisconsin Supreme Court primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Evans v. W.E.A. Insurance Trust, 361 N.W.2d 630, 122 Wis. 2d 1, 1985 Wisc. LEXIS 2107 (Wis. 1985).

Opinion

HEFFERNAN, C.J.

These are appeals from two judgments of the circuit court for Winnebago county. We affirm. This court on May 1, 1984, accepted these appeals on a consolidated certification of the court of appeals. Both cases arise out of claims under a health insurance plan covering employees of the Oshkosh public schools or members of their families. The plan is subject to the Federal Employee Retirement Income Security Act (ERISA), 29 U.S.C. sec. 1001, et seq. The administrator of the plan is the Wisconsin Education Association Insurance Trust (Trust).

Each of the claimants, Demaris Evans and Mary Jane Olson, underwent gastric bypass surgery for the correction of obesity. The claim for benefits to cover the expense of the surgery was denied in each case because the plan excludes “charges . . . which are not medically necessary,” and it was asserted by the Trust that the surgery was not medically necessary when measured by Trust-generated guidelines. Each claimant went through the claim-and-appeal procedure established by the Trust. When the Trust finally refused payment, Evans and Olson commenced separate actions in the circuit court to enforce their claimed right to benefits. Each action resulted in a summary judgment for the plaintiff, ordering payment by the Trust of the expenses of surgery, pre-judgment interest, and attorney’s fees. The W.E.A. Insurance Trust appealed the separate judgments. We affirm each of the judgments, concluding, as did the circuit courts in each case, that the denial of benefits was arbitrary and capricious and that the payment of benefits was required by the plan.

*5 It is agreed by the parties that the health insurance plan is subject to the provisions of ERISA, 29 U.S.C. sec. 1132. 1 It is also agreed by the parties that, although the rights of the parties arise under the aegis of the federal law, there is, in respect to a participant or beneficiary, concurrent jurisdiction, and these rights may be vindicated in the courts of the several states. Both parties assert that the standard to be applied when reviewing the decision of the trustees is whether it was arbitrary and capricious. They both rely upon the language of War die v. Central States, Southeast and Southwest Areas Pension Fund, 627 F.2d 820, 824 (7th Cir. 1980), cert. denied 449 U.S. 1112 (1981), quoting the language of Danti v. Lewis, 312 F.2d 345, 348 (D.C. Cir. 1962):

“ [W] hether the Trustees have acted arbitrarily, capriciously, or in bad faith; that is, is the decision of the Trustees supported by substantial evidence . . . .”

The court of appeals in its certification has posed a two-faceted problem in respect to the standard of review: *6 One, given the articulation of the standard of review as arbitrary and capricious, how is such standard to be measured — does the standard have the same meaning and requirements as that of the state arbitrary and capricious standard or is a special federal meaning or interpretation to be attached to that standard of review; and, two, is it appropriate to interpret “arbitrary and capricious” in the manner that is applied to the review of federal administrative agencies — several states have done so in ERISA cases — or is there a unique federal test of what is arbitrary and capricious that is applicable in the ERISA cases before us.

Additionally, the court of appeals asks this court to determine the “nature” of the civil action that may be brought in the state courts. This portion of the court of appeals’ certification we understand to be concerned with the procedure to be employed or the remedies afforded in actions in the state court. Are they actions at equity or at law? May money damages or awards be adjudged in state courts or are the powers of the state courts under the federal law only equitable in nature, i.e., can a state court merely set aside the trustees’ action for caprice or arbitrariness and order remand for further action or may it award benefits for which the record demonstrates an entitlement under the plan?

The facts of the two cases are strikingly similar. In both the Evans and the Olson cases, the plaintiff is an employee or the dependent of an employee of the Oshkosh public schools and is covered by a group health insurance plan which is subject to the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. sec. 1001 et seq. The same plan is involved in both cases and is administered by the Wisconsin Education Association Insurance Trust. The plan provides coverage for “necessary surgical procedure [s] ” resulting *7 from “accidental injury, sickness or Pregnancy.” The plan excludes “charges . . . which are not medically necessary.” The plan provides for an appeal procedure, in conformity with ERISA, under which a beneficiary may appeal the denial of a claim to the board of trustees.

Both plaintiffs underwent gastric bypass surgery and submitted claims to the Trust to cover the expenses of the surgery. On August 4, 1980, the Trust’s acting claims manager circulated a memo to claims adjusters, supervisors, auditors, and the underwriter, outlining guidelines for benefit determinations in cases of gastric bypass surgery. These guidelines were described by the claims manager as “Trust internal guidelines” and “Claims Department internal guidelines.” They were not incorporated into the plan as benefit plan amendments. The memorandum established five guidelines:

“To qualify for benefits payable for gastric bypass surgery :
“1) There must be evidence of a complicating medical problem ; such as, heart disease, diabetes, hypertension or arthritis. (The fact that a patient is currently taking medication to control the problem is considered sufficient evidence.)
“2) The participant should be 100% over ideal body weight.
“3) The participant should have carried this weight for a minimum of five years.
“4) The participant should have tried traditional methods of weight loss unsuccessfully.
“5) The participant must be considered psychologically a good candidate for surgery.”

In addition, the memorandum provided that:

“Any member who does not meet the above qualifications and wishes to apply for benefits will be referred, at our expense, to another physician for a second opinion.”

The memorandum also included the following explanation of the guidelines:

*8 “By modifying the guidelines in this manner, we are placing the emphasis on the presence of a complicating medical problem which necessitates the rapid weight loss.”

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Bluebook (online)
361 N.W.2d 630, 122 Wis. 2d 1, 1985 Wisc. LEXIS 2107, Counsel Stack Legal Research, https://law.counselstack.com/opinion/evans-v-wea-insurance-trust-wis-1985.