Lloyd SWITZER, Plaintiff-Appellee, v. WAL-MART STORES, INC., Defendant-Appellant

52 F.3d 1294, 19 Employee Benefits Cas. (BNA) 1619, 1995 U.S. App. LEXIS 10759, 1995 WL 293046
CourtCourt of Appeals for the Fifth Circuit
DecidedMay 12, 1995
Docket94-40263
StatusPublished
Cited by37 cases

This text of 52 F.3d 1294 (Lloyd SWITZER, Plaintiff-Appellee, v. WAL-MART STORES, INC., Defendant-Appellant) is published on Counsel Stack Legal Research, covering Court of Appeals for the Fifth Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Lloyd SWITZER, Plaintiff-Appellee, v. WAL-MART STORES, INC., Defendant-Appellant, 52 F.3d 1294, 19 Employee Benefits Cas. (BNA) 1619, 1995 U.S. App. LEXIS 10759, 1995 WL 293046 (5th Cir. 1995).

Opinion

WIENER, Circuit Judge.

In this ERISA 1 case Defendant-Appellant Wal-Mart Stores, Inc. (Wal-Mart), in its capacity as plan administrator of the Wal-Mart Stores, Inc. Health Benefit Plan (the Wal-Mart Plan), appeals from an adverse ruling of the district court ordering it to reconsider Plaintiff-Appellee Lloyd Switzer’s claimed medical expenses. The district court, after acknowledging that a lapse in Switzer’s health insurance coverage precluded him from obtaining a legal remedy, nevertheless concluded that Wal-Mart was “arbitrary and capricious” in denying Switzer’s claims and proceeded to fashion a so-called equitable remedy to achieve the result that the court found proper under the circumstances. Concluding that the court clearly erred in factual determinations upon which this case turns and erred as a matter of law in holding that Wal-Mart’s denial of Switzer’s claims was “arbitrary and capricious,” we are constrained to reverse its ruling, vacate its judgment, and render a take-nothing judgment against Switzer.

I

FACTS AND PROCEEDINGS

Switzer went to work for Wal-Mart in 1988, where he became a participant in the Wal-Mart Plan. His participation, and thus his health insurance coverage, ceased automatically when he quit his job with Wal-Mart in September 1990. Switzer elected to take COBRA 2 continuation of coverage as an option under Wal-Mart’s Health Insurance Program. He did all that was necessary to obtain such coverage and thereafter to maintain it — from the inception through the calendar month ending August 31, 1991 — by timely remitting the full amount of each monthly premium payment by personal cheek. 3

*1296 During the few months after Switzer left his Wal-Mart job, Wal-Mart made several administrative errors in connection with winding up his coverage under the Wal-Mart Plan, improperly deducting insurance premiums from Switzer’s accrued vacation pay. Wal-Mart reversed those incorrect deductions by the end of January 1991, however, and the errors have no direct bearing on Switzer’s ensuing health insurance difficulties, except to the extent that they figured into the district court’s determination that Switzer was justified in believing that Wal-Mart had a propensity for making such mistakes in administering its insurance plan.

Effective June 21, 1991, Switzer was rehired by Wal-Mart. As his prior employment termination in September 1990 constituted a true termination of employment and not a leave of absence, his return in June 1991 was tantamount to new employment and he was deemed a “new hire” under the Wal-Mart Plan. He was therefore subject to a 90-day waiting period before his re-enrollment in the Wal-Mart Plan could become effective. Switzer was aware of the delay in coverage under the Wal-Mart Plan resulting from that waiting period and of his need to maintain his COBRA coverage by making timely monthly premium payments until his coverage as an employee under the Wal-Mart Plan recommenced.

In addition to having received a summary plan description (SPD) detailing COBRA in ordinary, conversational language, Switzer was given, and had in his possession at all pertinent times, a monthly coupon book for his COBRA premiums. The coupon for the month of September 1991 specified that a premium payment of $82.46 was due and payable on August 28,1991. It also reflected that Switzer was entitled to a grace period of 30 days, and that the August 28th payment would be past due on September 27, 1991— the last day of the grace period. The coupon contained the following statement:

“IF PAYMENT IS NOT RECEIVED IN OUR OFFICE ON OR BEFORE PAST DUE DATE, COVERAGE WILL BE CANCELLED ON DATE LAST PAID.”

Switzer never remitted the August 28, 1991, payment, in whole or in part; he also did not remit any other payment thereafter. The last monthly payment that he made on his COBRA coverage was the one that was due late in July. Switzer paid it by check on July 26th, maintaining his COBRA coverage in full force and effect only through August 31, 1991. 4

Calculated on the basis of his re-employment date of June 21, 1991, Switzer’s 90-day waiting period for coverage under the Wal-Mart Plan expired approximately three-fourths of the way through the period of his September COBRA coverage, before Swit-zer’s COBRA coverage lapsed automatically on September 27th — effective retroactively to August 31st — due to non-payment. Apparently concluding that the premium for that fractional period was subject to proration, the district court found that Switzer’s final September COBRA payment should have been approximately $60 for that partial month, not the full $82.46 reflected on the coupon. 5

On October 4, 1991, Wal-Mart deducted a medical insurance premium from Switzer’s regular monthly paycheck — the first deduction following Switzer’s re-employment at Wal-Mart. The deduction covered Switzer’s initial, partial period of renewed coverage under the Wal-Mart Plan, from his initial eligibility date of September 21, 1991 through October 4,1991, the beginning of his first full month of coverage.

Also under date of October 4, Wal-Mart sent Switzer a computer-generated letter, which he received shortly thereafter. The *1297 letter informed him that his COBRA coverage would be canceled retroactively, effective to August 31, 1991, if he did not remit, by October 16, 1991, the $82.46 premium payment — an amount equal to a full, month’s COBRA premium — that had been due on August 28,1991 and had become past due on September 27, 1991. In addition to stating that cancellation of his COBRA coverage would be effective retroactively to August 31, 1991, the letter advised that canceled coverage could not be resumed. 6

Despite the obviously important nature of that information, Switzer elected to make no payment whatsoever. He also elected not to contact anyone at Wal-Mart about the October 4th letter or about the COBRA payment to which the letter referred. Rather, he took it upon himself, with the counsel of his wife only, to conclude (erroneously) that, inasmuch as his final COBRA period was a partial month and the figure mentioned in the letter was equal to a full month’s premium, the delinquent payment referred to in the letter must have been covered by Wal-Mart’s October 4th payroll deduction. Switzer came to this incorrect conclusion without inquiring about his misinterpretation, despite the fact (as found by the district court) that he was consciously interested in maintaining uninterrupted health insurance coverage.

Switzer had a known heart condition which constituted a pre-existing condition under the Wal-Mart Plan. That plan provided that all pre-existing conditions were excluded from coverage until the plan participant had been continuously covered for twelve consecutive months.

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Bluebook (online)
52 F.3d 1294, 19 Employee Benefits Cas. (BNA) 1619, 1995 U.S. App. LEXIS 10759, 1995 WL 293046, Counsel Stack Legal Research, https://law.counselstack.com/opinion/lloyd-switzer-plaintiff-appellee-v-wal-mart-stores-inc-ca5-1995.