Hammers v. Aetna Life Insurance

962 F. Supp. 1402, 1997 U.S. Dist. LEXIS 5421, 1997 WL 197413
CourtDistrict Court, D. Kansas
DecidedApril 15, 1997
DocketCivil Action No. 94-1302-FGT
StatusPublished
Cited by1 cases

This text of 962 F. Supp. 1402 (Hammers v. Aetna Life Insurance) is published on Counsel Stack Legal Research, covering District Court, D. Kansas primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Hammers v. Aetna Life Insurance, 962 F. Supp. 1402, 1997 U.S. Dist. LEXIS 5421, 1997 WL 197413 (D. Kan. 1997).

Opinion

MEMORANDUM AND ORDER

THEIS, District Judge.

This matter is before the court for entry of findings of fact and conclusions of law. Plaintiff brings this action under the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. § 1001 et seq., for the recovery of benefits under an employee health plan.

FINDINGS OF FACT

In the summer of 1993, while he was a graduate student at the University of Arizona, plaintiff William Bret Hammers was diagnosed with cancerous tumor, squamous cell carcinoma, on his tongue. After learning of this diagnosis, the plaintiff returned to Wichita, where his family lived, for treatment.

After consultation with several doctors, plaintiff elected to undergo a surgical excision of the tumor, coupled with a radical neck dissection to determine the extent of the cancer. Radiation therapy was not considered necessary for the plaintiffs case.

Dr. David Sargent, D.O., performed the surgery, removing the tumor and approximately 50 lymph nodes from the plaintiffs neck. The pathology report for the lymph nodes was negative, revealing no spread of the cancer.

At the time of plaintiffs August 1993 surgery, there was no observable metastasis. Following the surgery, plaintiffs doctors considered him to be in complete remission with no evidence of any active disease.

Plaintiffs treating physicians agreed that there was a risk of approximately 20% that the cancer would recur.

As part of Dr. Sargent’s usual follow-up for cancers of the head and neck, he examined plaintiff monthly following the surgery to check for any evidence of recurrence. These office visits occurred on September 9, 1993, October 14, 1993, November 29, 1993 and January 3, 1994. Dr. Sargent considered these visits to be follow-up care and treatment for the original cancer diagnosed and treated in August 1993.

At the office visits in September, October and November 1993 and in January 1994, Dr. Sargent saw no evidence of recurrence of the cancer.

On November 1, 1993, plaintiff went to work for Foster Design Company in Wichita, Kansas. Under Foster Design Company’s health plan, plaintiff was enrolled as a participant in an ERISA multi-employer health coverage plan administered by defendant Aetna Life Insurance Company. Under the plan, the plaintiff was entitled to health coverage after three continuous months of service at Foster Design Company, or on February 1,1994.

The preexisting condition limitation of the plan provides:

A condition is a preexisting condition if, during the last 90 days before the person’s current period of coverage became effective:
* treatment or services were received; or
* it was diagnosed or treated; or
* prescription drugs or medicines were prescribed or taken for that condition.
During the first 365 days of a person’s current period of coverage, Covered Medical Expenses do not include any expenses incurred for treatment of a “preexisting condition” or a condition which is caused or contributed to by or is a consequence of a “preexisting condition”.

Plaintiffs Exh. 2, p. 14.

During the ninety days before plaintiffs coverage took effect, Dr. Sargent saw plaintiff twice, on November 29,1993 and January 3, 1994. The doctor’s office notes reflect that these office visits were in follow up of the “squamous cell carcinoma of the right lateral tongue.” Dr. Sargent found no evidence of any recurrence of the cancer during those visits.

[1405]*1405On February 8, 1994, plaintiff returned to Dr. Sargent for his normally scheduled follow-up visit. During that visit, plaintiff pointed out a lump on his neck that he had noticed since his last visit. Plaintiff testified in his deposition that he had discovered the lump five to seven days earlier. Dr. Sargent’s office notes state that the plaintiff had noted a small lump on his neck for a month.

Upon discovery of the lump in plaintiffs neck, Dr. Sargent ordered a fine needle biopsy, which revealed further squamous cell cancer.

On February 16, 1994, plaintiff underwent additional surgery, followed by radiation therapy. The expenses for that surgery, radiation therapy and other related medical care form the subject matter of plaintiffs claim for recovery in this case. The parties have stipulated that plaintiff has incurred $104,871.69 in medical expenses, and that those charges are fair and reasonable.

Plaintiffs treating physicians agreed that the cancer discovered in February 1994 was a recurrence of the cancer diagnosed in the summer of 1993, and not a new primary tumor.

Dr. Sargent believed that the cancer was likely already in transit before the first surgery in August 1993.

Dr. Barbara Luder DeWitt, plaintiffs treating radiation oncologist, believed that the cancer was present as a microscopic disease which was not detected in the August 1993 neck dissection. Dr. DeWitt believed the disease was present throughout the entire period of August 1993 through February 1994. Oncologist David B. Johnson, M.D., agreed in this assessment.

When the plaintiffs claim for coverage was disputed, Dr. Sargent signed a note, drafted by plaintiffs father, which stated:

To Whom It May Concern:
Between 11/01/93 and 01/31/94,1 saw
W.B. (Bret) Hammers,
S.S.# 515-76-3601,
for the purpose of regularly scheduled checkups. During the time period from 11/01/93 to 01/31/94 he did not receive from me treatment or services for his current condition, his current condition was not diagnosed or treated, and no prescription drugs or medicines were prescribed or taken for his current condition.

Plaintiffs Exh. 1.

At the time the defendant made its decision denying coverage, the evidence before it indicated that the two diagnosed episodes of squamous cell carcinoma were related. The second episode was a recurrence of the initial cancer, and not a new primary tumor.

CONCLUSIONS OF LAW

Plaintiff brings this civil action pursuant to 29 U.S.C. § 1132(a)(1)(B), which authorizes a beneficiary to bring a civil action “to recover benefits due to him under the terms of his plan ...”

The court has subject matter jurisdiction pursuant to 29 U.S.C. § 1132(e) — (f) and 28 U.S.C. § 1331.

The parties have stipulated that the court has personal jurisdiction of the parties and that venue is proper in this district.

Although 29 U.S.C. § 1132(a)(1)(B) provides for judicial review of a denial of benefits due under a benefit plan, it does not set out the appropriate standard of review.

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Bluebook (online)
962 F. Supp. 1402, 1997 U.S. Dist. LEXIS 5421, 1997 WL 197413, Counsel Stack Legal Research, https://law.counselstack.com/opinion/hammers-v-aetna-life-insurance-ksd-1997.