Maune v. International Brotherhood of Electrical Workers, Local 1, Health & Welfare Fund

83 F.3d 959
CourtCourt of Appeals for the Eighth Circuit
DecidedMay 13, 1996
DocketNo. 95-2612
StatusPublished
Cited by1 cases

This text of 83 F.3d 959 (Maune v. International Brotherhood of Electrical Workers, Local 1, Health & Welfare Fund) is published on Counsel Stack Legal Research, covering Court of Appeals for the Eighth Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Maune v. International Brotherhood of Electrical Workers, Local 1, Health & Welfare Fund, 83 F.3d 959 (8th Cir. 1996).

Opinion

WOLLMAN, Circuit Judge.

Thomas and Helen Maune brought this action against the International Brotherhood of Electrical Workers, Local No. 1 Health and Welfare Fund (the “Fund”) and its trustees pursuant to the Employee Retirement Income Security Act (“ERISA”), 29 U.S.C. § 1132(a)(1)(B) after the Fund denied Helen Maune’s claim for health care benefits. The district court granted summary judgment for the Fund and awarded attorney’s fees, and the Maunes subsequently appealed. We affirm in part and reverse in part.

I.

Thomas Maune is a member of International Brotherhood of Electrical Workers, Local No. 1 (“IBEW”) and is a participant in the Fund. The Fund is an employee welfare benefit plan under ERISA, 29 U.S.C. § 1002(1) and is administered in accordance with the IBEW Fund Trust Agreement (the “Trust Agreement”) and the IBEW Fund Plan (the “Plan”). Helen Maune, as a depen-dant, is covered by the Plan.

In 1986, Ms. Maune was diagnosed with breast cancer and had her right breast removed. After a similar diagnosis was made in 1988, her left breast was removed. In 1989, Ms. Maune had silicone implants surgically inserted in both breasts. Following the operation, she began to experience joint pain, stiffness, fatigue, and low grade fevers. She was eventually referred to Dr. Klearman, a rheumatologist. In April 1992, Dr. Klear-man diagnosed Ms. Maune as having symptoms of arthritis. She also noted that Ms. Maune might have a mild case of lupus. Dr. Klearman did not recommend removal of the implants, noting that there were no hard data verifying a link between silicone breast implants and lupus. Instead, she prescribed Clinoril, an anti-inflammatory drug commonly used for arthritis. Ms. Maune went to see Dr. Khouri, a plastic surgeon, for a second opinion. Believing that the silicone breast implants were causing the symptoms, Dr. Khouri recommended removal.

In Ms. Maune’s follow-up visit to Dr. Klearman in May 1992, Dr. Klearman noted an improvement in Ms. Maune’s joint pain and inflammation. She disagreed with Dr. Khouri’s recommendation and suggested that Ms. Maune wait one year before removing the implants, again noting that there were no medical data to suggest that Ms. Maune’s illness was related to the implants. In July 1992, Dr. Klearman noted that Ms. Maune had no muscle tenderness and that her joint exam was normal. Her notes from that visit also reflect that Ms. Maune was doing “fairly well” with her joint pain and fatigue.

Ms. Maune decided to proceed with the surgery and sought pre-certification from the Fund. Dr. Farrier, the Fund’s medical consultant, concluded that the surgery was not medically necessary. Specifically, he pointed to Dr. Klearman’s notes that stated that Ms. Maune had symptoms of arthritis and had responded favorably to the Clinoril; the lack of evidence that Ms. Maune actually had lupus; and the absence of any link between silicone breast implants and lupus. [962]*962Dr. Farrier also noted that Dr. Khouri had incorrectly assumed that Ms. Maune had been diagnosed with lupus when in fact no such diagnosis had ever been made. By letter dated September 11, 1992, the Fund denied the Maunes’ request for pre-certification, finding that the surgery was not medically necessary.

The Maunes then submitted additional information in support of their claim, including a letter from Dr. Young, the surgeon who had inserted the implants. In his letter, Dr. Young stated that he believed there to be a connection between breast implants and autoimmune diseases such as lupus. He submitted a medical journal article and the results of his own study purporting to show such a link. After reviewing the additional evidence, Dr. Farrier again concluded that the procedure was not medically necessary. He discounted Dr. Young’s study because it was ongoing and had not been subjected to peer review. Dr. Farrier was not persuaded by medical journal evidence that had been submitted because it failed to indicate that silicone breast implants cause autoimmune diseases such as lupus.

The Maunes also submitted a letter from Dr. Klearman. Modifying her earlier opinion, Dr. Klearman noted that an increasing number of reports link silicone breast implants and lupus. She felt the procedure should be covered by the Plan because Dr. Khouri “strongly recommended” removal. Dr. Farrier considered the letter, but did not change his opinion that the procedure was not medically necessary. By letter dated September 23, 1992, the Fund again denied ■ pre-certification, and the Maunes subsequently appealed the denial.

On October 6, 1992, while the Fund was considering her appeal, Ms. Maune underwent surgery to remove the implants. After considering all of the evidence previously submitted by the-Maunes, as well as Ms. Maune’s medical records, the committee denied the appeal on October 13, 1992. The Maunes then filed a post-operative claim with the Fund. After reviewing Ms. Maune’s hospital records, Dr. Farrier concluded that the surgery was not done for any proven medical condition. On January 8, 1993, the Fund denied the claim and advised the Maunes of their appeal rights.

In April 1993, the Maunes appealed the denial of benefits. They submitted additional evidence, including letters from Dr. Khouri and Dr. Klearman, to bolster their claim for benefits. Both Dr. Khouri and Dr. Klearman noted that Ms. Maune showed improvement in her previous symptoms following the surgery. After examining the evidence, Dr. Farrier renewed his prior findings because he was not persuaded that Ms. Maune’s improvement was related to the removal of the implants. He noted that Ms. Maune had responded well to the Clinoril before the surgery and to Ansaid, a drug prescribed for her post-surgery. On June 25, 1993, the Fund again denied the claim after reviewing the additional evidence.

Having exhausted their administrative remedies, the Maunes filed suit against the Fund and its trustees. The district court granted the Fund’s motion for summary judgment and awarded the Fund approximately $25,000 in attorney’s fees. The Maunes appeal, claiming that the district court erred in granting summary judgment for the Fund, in granting the Fund’s motion for stay of discovery pending a ruling on the summary judgment motion, and in awarding attorney’s fees to the Fund.

II.

We review a grant of summary judgment de novo. Davidson & Schaaff, Inc. v. Liberty Nat’l Fire Ins. Co., 69 F.3d 868, 870 (8th Cir.1995). Because the Trust Agreement and the Plan gave the trustees discretionary authority to determine eligibility of benefits, the district court reviewed the trustees’ decision that the procedure was not medically necessary for abuse of discretion. See Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115, 109 S.Ct. 948, 956-57, 103 L.Ed.2d 80 (1989); Collins v. Central States Health & Welfare Fund, 18 F.3d 556, 559 (8th Cir.1994). We review the district court’s application of this standard de novo. Bolling v. Eli Lilly & Co.,

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