King v. Blue Cross & Blue Shield of Illinois

104 F. Supp. 3d 1062, 61 Employee Benefits Cas. (BNA) 1192, 2015 U.S. Dist. LEXIS 66963, 2015 WL 2385684
CourtDistrict Court, S.D. California
DecidedMay 13, 2015
DocketCase No. 3:13-CV-1254-CAB-JMA
StatusPublished

This text of 104 F. Supp. 3d 1062 (King v. Blue Cross & Blue Shield of Illinois) is published on Counsel Stack Legal Research, covering District Court, S.D. California primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
King v. Blue Cross & Blue Shield of Illinois, 104 F. Supp. 3d 1062, 61 Employee Benefits Cas. (BNA) 1192, 2015 U.S. Dist. LEXIS 66963, 2015 WL 2385684 (S.D. Cal. 2015).

Opinion

ORDER ON MOTIONS FOR SUMMARY JUDGMENT

CATHY ANN BENCIVENGO, District Judge.

This matter is before the Court on Defendants’ motions for summary judgment. Specifically, Defendants United Parcel Service of America, Inc. (“UPS”), and UPS Health and Welfare Package for Retired Employees (the “Plan,” and together with UPS, the “UPS Defendants”) filed a motion for summary judgment [Doc. No. 48] on the first, second, third and fifth causes of action. Defendant Health Care Service Corporation doing business as Blue Cross and Blue Shield of Illinois (“Blue Cross”) joined the UPS Defendants’ motion. [Doc. No. 49.] Blue Cross also filed a separate motion for summary judgment on the fourth cause of action. [Doc. No. 50.] The motions have been fully briefed, and the Court has deemed the motions suitable for determination without a hearing. For [1066]*1066the reasons discussed below, the motions are granted.

I. Background

A. The UPS Retiree Plan

Plaintiff Gary King retired from UPS on March ■ 14, 2011. Upon his retirement, King’s wife, Linda King, became a participant in and beneficiary of the Plan. The Summary Plan Description (the “SPD”) for the Plan describes the substantive benefits provided and the procedures for appealing denials of claims. [Doc. No. 15-3 at 3.]

1. Lifetime Maximum Benefit Language from the Plan

The SPD states:

The Lifetime Beneftt Maximum
Up to $500,000 in lifetime medical benefits (unlimited in HMO Option) can be paid for each person participating in the UPS Health and Welfare Package for Retired Employees. Only benefits paid while you receive coverage as a retired employee count toward the $500,000 total. ...

[Id. at 136J In September 2010, the Retiree Plan issued á “Summary of Material Modifications” (the “2010 SMM”) that amended the Plan. The 2010 SMM lists both the UPS Health and Welfare Package (which applies to active employees) and the Plan in the heading. A footer on the last page the 2010 SMM states: “This notice is intended to fulfill UPS’s legal obligation to notify employees of material changes to the UPS Health and Welfare Package .and the UPS Health and Welfare Package for Retired Employees. This notice formally amends the coverage available under the Plans.”' [Doc. No. 15-3 at 34.]

Immediately below the header on the first page, the 2010 SMM eontáins the following language across the page (italics in original):

This notice details Plan improvements, changes, clarifications, and required notifications effective January 1, 2011, unless otherwise noted. Items noted with an asterisk (*) do not apply to retirees or their covered dependents. You should keep this with your UPS Health and Welfare Package and UPS Health and Welfare Package for Retired Employees Summary Plan Description for future reference.

[Doc. No. 15-3 at 31.] Immediately below this italicized' language the text divides into two columns. At the top of the left-hand column is the heading “Health Cafe Reform *” in bold and using what Defendants described in them motions to dismiss as “Ariel” [sic] font, followed by a paragraph of single-spaced text. After this paragraph, there is a double-space followed by the heading “Grandfather Plan Status” in bold and in the same character size as the previous heading, but this time in what Defendants described as “Times New Roman” font. Under this second heading are two paragraphs of single-spaced text separated by a double-space. The first sentence of the first paragraph reads: “UPS believes this Plan is a ‘grandfathered health plan’ as defined under PPACA.”1 The last sentence of the first paragraph reads: “For example, PPACA’s prohibition against lifetime limits on >‘essential benefits’ does apply to grandfathered health plans.” '

Underneath' these two paragraphs is a third heading also in bold Times New Roman font followed by five paragraphs, each separated by a double-space, taking the reader onto the second page of the 2010 SMM. Approximately a third of the way down the left-hand column on the second [1067]*1067page is a fourth heading, “Elimination of Lifetime Maximum Benefits,” again in bold Times New Roman font. The first sentence of the single paragraph under this fourth heading reads: “Lifetime dollar limits on aggregate benefits will be eliminated from your Plan effective January 1, 2011.” There are then three more bold headings in Times New Roman font leading onto the second column of the second page. Then, there is the bold heading, “Mental Health Parity”, which is in the same Arial font as the very first heading for “Health Care Reform”, followed by single-spaced text and then a bold heading in Times New Roman, and so on. The only asterisk in the entire document is the one that appears following the initial “Health Care Reform *” heading.

2. Plan Administration and Appeals Process

UPS is the Plan Administrator and the Plan Sponsor. [Doc. No. 15-3 at 143144.] The SPD states:

[UPS] shall have the exclusive right and discretion to interpret .the terms and conditions of the Plan, and to decide all matters arising in its administration and operation, including questions of fact and issues pertaining to eligibility for, and the amount of, benefits to be paid by the Plans. Any such interpretation or decision shall, subject to the claims procedure described herein, be conclusive and binding on all interested persons .... The Plan Administrator may delegate certain discretionary authority to one or more committees.

[Doc. No. 15-3 at 143.] The SPD also states that UPS is allowed to delegate its administrative duties to outside administrative service providers and states that medical coverage under the Plan is administered by several entities, including Defendant Blue Cross. [Id.]

The SPD describes a two level appeals process for denied claims. The first level appeal must be filed with the claims administrator (i.e., Blue Cross) within 180 days of receipt of the initial written deniál from the claims administrator. [Doc. No. 15-3 at 131.] If the first level appeal is denied, a second level appeal must be filed with the UPS Claims Review Committed (“CRC”) within 60 days of receipt of the first level appeal denial from the claims administrator. [Doc. No! 153 at 132.]

B. Plaintiffs Medical Claim

In November 2012, Mrs. King suffered an infection which required back surgery and extensive post-surgery medical care and rehabilitation. It appears that Mrs. King, or someone on her behalf, contacted Blue Cross in some manner on multiple occasions to seek pre-approval for some of her medical procedures. Along these lines, Plaintiffs opposition includes several letters dated between November 28, 2012, and- February 11, 2013, from Blue Cross to Mrs. King indicating approval of certain procedures “as medically necessary as defined by the member’s Health Care Benefits booklet or [SPD].” [Doc. No. 59-2 at 5-23.]2 The letters also state:

Approval through the Health Care Management Department is not a guarantee of payment of benefits.

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Bluebook (online)
104 F. Supp. 3d 1062, 61 Employee Benefits Cas. (BNA) 1192, 2015 U.S. Dist. LEXIS 66963, 2015 WL 2385684, Counsel Stack Legal Research, https://law.counselstack.com/opinion/king-v-blue-cross-blue-shield-of-illinois-casd-2015.