Kornman v. Blue Cross/Blue Shield of La.

662 So. 2d 498, 1995 WL 565089
CourtLouisiana Court of Appeal
DecidedSeptember 26, 1995
Docket94-CA-306
StatusPublished
Cited by1 cases

This text of 662 So. 2d 498 (Kornman v. Blue Cross/Blue Shield of La.) is published on Counsel Stack Legal Research, covering Louisiana Court of Appeal primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Kornman v. Blue Cross/Blue Shield of La., 662 So. 2d 498, 1995 WL 565089 (La. Ct. App. 1995).

Opinion

662 So.2d 498 (1995)

Janette M., wife of/and Charlie KORNMAN, Individually and on Behalf of Their Dependent Son, Richard Jay Kornman
v.
BLUE CROSS/BLUE SHIELD OF LOUISIANA.

No. 94-CA-306.

Court of Appeal of Louisiana, Fifth Circuit.

September 26, 1995.
Rehearing Denied November 17, 1995.

*499 David C. Loeb, Jack E. Morris, Molaison, Price & Loeb, LLP, Metairie, Marion F. Edwards, Gretna, for plaintiffs-appellees.

Sylvan J. Steinberg, Robin H. Graves, Bronfin & Heller, New Orleans, for defendant-appellant.

Before GRISBAUM, WICKER and GOTHARD, JJ.

GRISBAUM, Judge.

INTRODUCTION

Defendant appeals from the trial court's judgment finding plaintiffs were entitled to benefits for Richard Kornman's 11-month confinement/treatment for drug abuse under the health insurance policy provided by defendant along with penalties and attorney's fees. We affirm.

ISSUES

1. Whether the Coast Quality Construction Company's (Coast) Medical Expense Plan (MEP) is a plan under the Employee Retirement Income Security Act (ERISA);

2. Whether Richard Kornman was covered as a dependent under Coast's MEP;

a. Whether Richard was capable of self-support;
b. Whether Charlie Kornman was required to provide proof of Richard's incapacity and dependency when Richard reached age 25, the limiting age;
c. Whether Blue Cross could have denied Richard's coverage based on information in a health questionnaire;

*500 3. Whether Richard Kornman's treatment at the Coliseum was covered by the terms of the policy;

a. Whether Richard's treatment at the Coliseum fell during the 365-day exclusion period for pre-existing conditions;
b. Whether Richard was treated for substance abuse or for a mental condition for which there is a policy limit of $5,000;
c. Whether Richard's treatment at the Coliseum Medical Center was medically necessary.

FACTS

Plaintiffs, Charlie, Janette and Richard Kornman[1], filed suit in state court in June 1988 against Blue Cross/Blue Shield of Louisiana[2] (Blue Cross), seeking medical benefits allegedly owed them under a medical expense plan (MEP) established by their employer, Coast Quality Construction Company (Coast), and insured by defendant. Charlie Kornman was both the owner and an employee of Coast.

Plaintiffs seek recovery for medical expenses incurred by Richard Kornman during an eleven-month stay at the Coliseum Medical Center ("Coliseum"), for treatment for substance abuse. Plaintiffs maintain Richard was covered as a dependent under Charlie Kornman's policy. Alternatively, plaintiffs maintain Richard was covered independently as an employee of Coast. Blue Cross denied coverage under both assertions.

Blue Cross attempted to remove the matter to federal court on the basis ERISA governed but the Eastern District Court found there was no ERISA plan and remanded the matter to the state court. After a sporadic four day trial, the trial court found ERISA did not apply, Richard was covered by Blue Cross as Charlie's dependent and was, accordingly, owed benefits. The trial court awarded plaintiffs $174,423.64 for benefits, $37,940.25 for attorneys' fees, $174,423.64 in penalties, $16,351.02 in costs and expert fees, plus interest. Blue Cross appeals this judgment on several grounds.

ISSUE ONE: Is Coast's MEP an ERISA plan?

On July 21, 1988, defendant-appellant filed a petition of removal on the basis plaintiffs' cause of action for the recovery of benefits under Coast's medical expense plan (MEP) was governed by ERISA and, thus, a federal question existed for federal court jurisdiction. The United States District Court for the Eastern District of Louisiana remanded the matter finding Coast's MEP did not qualify as an ERISA plan under Taggart Corp. v. Life & Health Benefits Admin., 617 F.2d 1208 (5th Cir.1980), cert. denied, 450 U.S. 1030, 101 S.Ct. 1739, 68 L.Ed.2d 225 (1981).[3]

On remand, appellant reurged its argument to the state trial court that ERISA applied. Adopting the reasons set forth in the Eastern District Court's order, the trial court likewise found ERISA did not apply.

On appeal, despite the findings of both the Eastern District Court and the state trial court, Blue Cross continues to assert ERISA governs this case.[4] Blue Cross bases its argument on recent federal Fifth Circuit cases[5], decided after the 1988 Eastern District *501 Court's order of remand, which severely restrict Taggart Corp. v. Life & Health Benefits Admin., supra, the sole case relied on by both the Eastern District Court and the trial court in determining Coast's MEP was not an ERISA plan. Blue Cross asserts Coast's MEP would qualify as an ERISA plan under the guidelines established by these new federal cases. However, plaintiffs argue the new federal cases cannot be retroactively applied because to do so would divest them of a vested right, namely the right to penalties and attorney's fees, given to them as a matter of state law.[6]

In matters involving federal law, we, as a state court, are only "bound" by decisions of the United States Supreme Court. Gaspard v. Transworld Drilling Co., 468 So.2d 692 (La.App. 3 Cir.1985), writ denied, 474 So.2d 1304 (La.1985), cert. denied, 475 U.S. 1067, 106 S.Ct. 1382, 89 L.Ed.2d 607 (1986). Federal appellate court decisions, such as decisions rendered by the Federal Fifth Circuit, are merely persuasive. State v. White, 321 So.2d 491 (La.1975). As a state court, we have authority to render decisions based on our own interpretation of federal law provided federal courts do not have exclusive jurisdiction over the matter. ASARCO Inc. v. Kadish, 490 U.S. 605, 109 S.Ct. 2037, 104 L.Ed.2d 696 (1989). Thus, since we share concurrent jurisdiction with federal courts over ERISA matters[7], we are not technically bound by the newer federal cases relied upon by appellant.

The Employee Retirement Income Security Act (ERISA) was enacted in 1974 for the purpose of protecting workers participating in employee benefit plans from misappropriation and misuse of funds paid into the plan and other abuses by regulating the administration of the plans. 29 USC § 1001(b).[8] ERISA applies to any "employee benefit plan" established or maintained by any employer or employee organization engaged in commerce, or in any industry or activity affecting commerce. 29 USC § 1003(a). While ERISA regulates two types of benefit programs, pension plans and welfare plans, our concern is with the welfare plan. An "employee welfare benefit plan" is defined as

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662 So. 2d 498, 1995 WL 565089, Counsel Stack Legal Research, https://law.counselstack.com/opinion/kornman-v-blue-crossblue-shield-of-la-lactapp-1995.