Lanclos v. Guardian Life Insurance Co. of America

607 So. 2d 1089, 1992 La. App. LEXIS 3532, 1992 WL 320088
CourtLouisiana Court of Appeal
DecidedNovember 4, 1992
DocketNo. 91-946
StatusPublished
Cited by1 cases

This text of 607 So. 2d 1089 (Lanclos v. Guardian Life Insurance Co. of America) 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
Lanclos v. Guardian Life Insurance Co. of America, 607 So. 2d 1089, 1992 La. App. LEXIS 3532, 1992 WL 320088 (La. Ct. App. 1992).

Opinion

DOUCET, Judge.

The Guardian Life Insurance Company of America (Guardian) appeals a district court judgment finding health insurance [1090]*1090coverage in connection with two separate claims made by the plaintiff. Guardian also appeals the district court’s award of penalties and attorney’s fees.

The .plaintiff, Cindy Landos, was employed by St. Landry Juvenile Services, Inc., a quasi-governmental agency involved in juvenile rehabilitation. As an employee of St. Landry Juvenile Services, Ms. Láñe-los was covered under a group health insurance policy provided by Guardian.

In 1987, Ms. Landos became pregnant with her first child. In August, she went into premature labor. She was hospitalized and given medication to stop her labor. In early September, Ms. Landos was again hospitalized with premature labor. The placenta separated (placenta abrupta) and her son was delivered prematurely.

In 1990, Ms. Landos again became pregnant. In June 1990, she again went into premature labor. As a result, a child, Johnathan, was born prematurely and died only four hours after his birth. Guardian refused to pay benefits for Ms. Landos’ 1987 delivery and for Johnathan’s care and treatment. As a result, Ms. Landos filed this suit to recover benefits plus penalties and attorney’s fees under La.R.S. 22:657.

After a trial on the merits, judgment was rendered in favor of Ms. Landos on both claims and for penalties and attorney’s fees. Guardian appeals.

ERISA

Guardian first argues that the policies issued to St. Landry Juvenile Services, Inc. were governed by ERISA. It argues that, as a result, the trial court was, in fact, a reviewing court and applied the wrong standard of review. Additionally, they argue that penalties and attorney’s fees are not available where ERISA applies. ERISA applies to certain employee benefit plans. Employee benefit plans are defined by 29 U.S.C.S. § 1002 as follows:

For purposes of this title:

(1) The terms “employee welfare benefit plan” and “welfare plan” mean any plan, fund, or program which was heretofore or is hereafter established or maintained by an employer or by an employee organization, or by both, to the extent that such plan, fund, or program was established or is maintained for the purpose of providing for its participants or their beneficiaries, through the purchase of insurance or otherwise, (A) medical, surgical, or hospital care or benefits, or benefits in the event of sickness, accident, disability, death or unemployment, or vacation benefits, apprenticeship or other training programs, or day care centers, scholarship funds, or prepaid legal services, or (B) any benefit described in section 802(c) of the Labor Management Relations Act, 1947 [29 USCS § 186(c)] (other than pensions on retirement or death, and insurance to provide such pensions).
(2)(A) Except as provided in subpara-graph (B), the terms “employee pension benefit plan” and “pension plan” mean any plan, fund, or program which was heretofore or is hereafter established or maintained by an employer or by an employee organization, or by both, to the extent that by its express terms or as a result of surrounding circumstances such plan, fund, or program—
(i) provides retirement income to employees, or
(ii) results in a deferral of income by employees for periods extending to the termination of covered employment or beyond, regardless of the method of calculating the contributions made to the plan, the method of calculating the benefits under the plan or the method of distributing benefits from the plan. (B) The Secretary may by regulation prescribe rules consistent with the standards and purposes of this Act providing one or more exempt categories under which—
(i) severance pay arrangements, and
(ii) supplemental retirement income payments, under which the pension benefits of retirees or their beneficiaries are supplemented to take into account some portion or all of the increases in the cost of living (as deter[1091]*1091mined by the Secretary of Labor) since retirement,
shall, for purposes of this title, be treated as welfare plans rather than pension plans. In the case of any arrangement or payment a principal effect of which is the evasion of the standards or purposes of this Act applicable to pension plans, such arrangement or payment shall be treated as a pension plan.
(3)The term “employee benefit plan” or “plan” means an employee welfare benefit plan or an employee pension benefit plan or a plan which is both an employee welfare benefit plan and an employee pension benefit plan.

Plans covered by ERISA are delineated in 29 U.S.C.S. § 1003:

(a) Except as provided in subsection (b) and in sections 201, 301, and 401 [29 USCS §§ 1051, 1081, and 1101], this title shall apply to any employee benefit plan if it is established or maintained—
(1) by any employer engaged in commerce or in any industry or activity affecting commerce; or
(2) by any employee organization or organizations representing employees engaged in commerce or in any industry or activity affecting commerce; or
(3) by both.
(b) The provisions of this title shall not apply to any employee benefit plan if—
(1) such plan is a governmental plan (as defined in section 3(32) [29 USCS § 1002(32)]);
(2) such plan is a church plan (as defined in section 3(33) [29 USCS § 1002(33) ]) with respect to which no election has been made under section 410(d) of the Internal Revenue Code of 1986 [26 USCS § 410(d)];
(3) such plan is maintained solely for the purpose of complying with applicable workmen’s compensation laws or unemployment compensation or disability insurance laws;
(4) such plan is maintained outside of the United States primarily for the benefit of persons substantially all of whom are nonresident aliens; or
(5)such plan is an excess benefit plan (as defined in section 3(36) [29 USCS § 1002(36)]) and is unfunded.

The burden of proving an ERISA pre-emption lies with the defendant. Settles v. Golden Rule Insurance Company, 927 F.2d 505 (C.A. 10th Cir.1991). An employer’s purchase of insurance or payment of premiums is not alone enough to establish a plan, fund, or program. Kidder v. H. & B. Marine, Inc., 932 F.2d 347 (C.A. 5th Cir.1991); Donovan v. Dellingham, 688 F.2d 1367 (C.A. 11th Cir.1982).

After reviewing the record as a whole, we find nothing of record that would tend to prove that an ERISA pre-emption applies here. In the absence of proof, the provisions of ERISA will not be applied to Ms. Landos’ claim.

COVERAGE

Guardian next argues that the policies did not provide coverage for the claims made by Ms. Landos.

La.C.C. art. 2046 provides that:

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Bluebook (online)
607 So. 2d 1089, 1992 La. App. LEXIS 3532, 1992 WL 320088, Counsel Stack Legal Research, https://law.counselstack.com/opinion/lanclos-v-guardian-life-insurance-co-of-america-lactapp-1992.