Janet Carr v. The Gates Health Care Plan

195 F.3d 292, 23 Employee Benefits Cas. (BNA) 2017, 1999 U.S. App. LEXIS 26521, 1999 WL 959658
CourtCourt of Appeals for the Seventh Circuit
DecidedOctober 21, 1999
Docket99-1362
StatusPublished
Cited by68 cases

This text of 195 F.3d 292 (Janet Carr v. The Gates Health Care Plan) is published on Counsel Stack Legal Research, covering Court of Appeals for the Seventh Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Janet Carr v. The Gates Health Care Plan, 195 F.3d 292, 23 Employee Benefits Cas. (BNA) 2017, 1999 U.S. App. LEXIS 26521, 1999 WL 959658 (7th Cir. 1999).

Opinions

BAUER, Circuit Judge.

Janet Carr was denied benefits under the Gates Health Care Plan (“the Plan”), an employee welfare benefit plan, because the treatment rendered related to a 1979 gastric stapling surgery, specifically excluded under the Plan. The Plan is sponsored by the Gates Corporation, and provides medical benefits, subject to certain limitations and exclusions, to eligible employees of the corporation and their depen-dants. The District Court held that the Health Care Benefits Review Committee (“the Committee”) has sole discretion to interpret the Plan. After exhausting her administrative remedies, Carr initiated a suit under ERISA, 29 U.S.C. § 1132(a)(1)(B), in state court to recover benefits under an employee welfare plan. The Plan then removed the case to the United States District Court of the Central District of Illinois. On cross-motions for summary judgment, the district court determined that the Plan did not arbitrarily and capriciously deny Carr’s claim, granted the Plan’s motion for summary judg[294]*294ment and denied Carr’s motion. We affirm the district court’s decision.

I. Background

In 1979, Carr underwent a gastric stapling procedure, not covered by the Plan, for the purpose of weight loss. In 1992, she sought treatment to revise the procedure at the University of Iowa Hospitals and Climes in Iowa City, Iowa. This treatment was specifically excluded from coverage under the terms of the Plan. Carr appealed and the Plan agreed to cover the procedure but told her that “any future surgery related to this specific condition could not be covered unless a benefit under the plan at that time.”

In 1995, Carr suffered further complications from her 1979 surgery. Between June 21, 1995 and December 30, 1995 Carr underwent a series of surgeries to alleviate her condition. Carr submitted the bills for these surgeries to the Plan. After review of Carr’s file, the Plan’s Medical Director denied her claims under the Plan, which specifically excluded services and benefits for cosmetic or surgical procedures related to the enlargement, reduction, implantation or change in appearance of a portion of the body and gastric stapling or diversion for weight loss. Carr appealed this decision to the Committee, who retained independent physician specialist Dr. John Q. Gallagher. Carr submitted additional medical records and information for consideration by the specialist. Dr. Gallagher opined that the surgeries during June and December of 1995 were related to the original gastric surgery performed in 1979. After a final review, the Committee sent Carr a 10-page letter detailing its decision and reasoning for denying her claim. The Committee’s decision was based on its policy to exclude conditions or problems directly or indirectly related to, or caused by, gastric stapling or weight-loss diversion procedures, even if the benefits and services are medically necessary.

Carr requested an additional review by the Committee. The Committee again reviewed her file and the transcript of the evidence deposition of her attending physician, Dr. Doherty. The Committee reaffirmed its decision that the treatment rendered was related to the gastric stapling procedure and therefore not covered under the Plan.

Carr then filed suit to have the Committees decision overturned.

II. Analysis

We review the district court’s order granting summary judgment de novo. Larsen v. City of Beloit, 130 F.3d 1278, 1281 (7th Cir.1997). Where the plan gives the administrator discretion to interpret the plan terms or determine benefits eligibility courts review the denial of benefit claims under ERISA, 29 U.S.C. § 1132(a)(1)(B), using the arbitrary and capricious standard. Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115, 109 S.Ct. 948, 956-57, 103 L.Ed.2d 80 (1989); Butler v. Encyclopedia Brittanica, Inc., 41 F.3d 285, 288 (7th Cir.1994). Under the arbitrary and capricious standard, the administrator’s decision will only be overturned if it is “downright unreasonable.” Butler at 291. A denial of benefits will not be set aside if the denial was based upon a reasonable interpretation of the plan documents. Loyola Univ. of Chicago v. Humana Ins. Co., 996 F.2d 895, 898. If the administrator makes an informed judgment and articulates an explanation for it that is satisfactory in light of the relevant facts, then the administrator’s decision is final. Id. (quoting Exbom v. Central States, Southeast and Southwest Areas Health and Welfare Fund, 900 F.2d 1138, 1141 (7th Cir.1990)). Under the arbitrary and capricious standard, it is not our function to decide whether we would reach the same conclusion as the Plan or even rely on the same authority. Cvelbar v. CBI Ill. Inc., 106 F.3d 1368, 1379 (7th Cir.1997). Instead, the court is only to determine if the decision was downright unreasonable. Mers v. Marriott Int’l Group & Accidental [295]*295Death and Dismemberment Plan, 144 F.3d 1014, 1021 (7th Cir.1998).

In this case, it is undisputed that the Committee is authorized, in its sole discretion, to interpret the Plan. This discretion empowers the Committee to construe disputed or ambiguous terms under the Plan, decide all questions of fact that may arise and determine the right of any member to a benefit, in accordance with the Plan. Under the Plan, such interpretations or determinations made by the Committee in good faith shall be conclusive and binding on all parties.

Carr argues that treatment for life-threatening complications of a non-covered act should be covered. In support of her argument she relies on dicta from Fuller v. CBT Corp., 905 F.2d 1055, 1057 (7th Cir.1990), which says that a complication incident to a non-covered procedure may be covered. The court in Fuller, however did not expand on this argument because the issue was not presented to the Court and therefore was waived. Id. Moreover, the Fuller court did not address the authority and the broad discretion of the plan administrator nor the scope of the plan at issue for us to comment. The court in Fuller did recognize the broad discretion of the plan administrator to interpret the plan and that the court will only overturn the decision if it was downright unreasonable. Id. at 1058.

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Bluebook (online)
195 F.3d 292, 23 Employee Benefits Cas. (BNA) 2017, 1999 U.S. App. LEXIS 26521, 1999 WL 959658, Counsel Stack Legal Research, https://law.counselstack.com/opinion/janet-carr-v-the-gates-health-care-plan-ca7-1999.