Mitchell v. Dialysis Clinic, Inc.

18 F. App'x 349
CourtCourt of Appeals for the Sixth Circuit
DecidedAugust 24, 2001
DocketNo. 00-5467
StatusPublished
Cited by9 cases

This text of 18 F. App'x 349 (Mitchell v. Dialysis Clinic, Inc.) is published on Counsel Stack Legal Research, covering Court of Appeals for the Sixth Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Mitchell v. Dialysis Clinic, Inc., 18 F. App'x 349 (6th Cir. 2001).

Opinion

KENNEDY, Circuit Judge.

In this ERISA action, plaintiffs, Danny and Brenda Mitchell, seek to recover medical expenses related to Danny’s injuries from Brenda Mitchell’s employer, defendant, Dialysis Clinic, Inc. (DCI). The plaintiffs assert Brenda’s employee benefit plan (Dialysis Clinic, Inc. Employees Benefit Trust (the Plan)) entitles them to recover these expenses. The Mitchells ap[351]*351peal the district court’s decision granting defendants summary judgment. On appeal, the Mitchells argue (1) the district court ignored the plain meaning of the Plan and (2) the district court erred by applying an arbitrary-and-capricious standard of review to the Plan administrator’s decision to deny coverage.

We find arbitrary and capricious the appropriate standard of review of the Plan’s administrative decision. Applying that standard, we do not find fault in the administrator’s interpretation against the Mitchells’ claim. As a result, we affirm.

I.

As an employee of DCI, Brenda Mitchell is covered by DCI’s self-funded employee benefits Plan. As Brenda’s spouse, Danny Mitchell is covered by the Plan as well. The Plan, which is governed by the Employee Retirement Security Act of 1974, as amended, 29 U.S.C. § 1001 et seq, gives the administrator, DCI, “the power to construe and interpret the provisions of the plan.” J.A. at 132. That responsibility falls mainly to DCFs human resources director, David Hagewood. See J.A. 124.

Accordingly, he was responsible for determining whether the claim Mrs. Mitchell submitted for Danny’s injuries was covered by the Plan. Mr. Mitchell, a self-employed sub-contractor, had broken his left ankle and right foot as a result of falling from scaffolding while working. On July 21, 1998, DCI sent Mrs. Mitchell an application for benefits form and inquired whether anyone else was responsible for the injury. See J.A. at 308. She returned the application and noted that “Danny is a self[-]employed sub-contractor responsible for himself. There is no workmans [sic] comp or other known responsible party.” Upon receiving this response, Scott Graal-man, who was apparently handling the claim, e-mailed Vickie Cochran, a DCI employee, inquiring as to whether the Plan would cover Mitchell, who Graalman believed, “was injured at work, on the job.... His employer does not carry workers comp insurance.” J.A. at 310. A printed copy of the e-mail has a hand written note, presumably from Cochran, saying that “Exempt if less than 5” employees, “will require subrogation.” The Mitchells suggest this note indicates the Plan’s employees believed Mr. Mitchell was entitled to benefits.

On September 18, 1998, DCI informed Mrs. Mitchell, in an Explanation of Benefits form, that “Charges incurred as a result of an on-the-job injury or illness are not covered.” J.A. at 222. The form provided no further explanation. On October 3, 1998, Ms. Mitchell sought further explanation by way of a letter, requesting an answer to why her claim had been denied so she could appeal the decision. J.A. 224. In response, on October 8, Mr. Hagewood, explained in a letter that “[t]he claims were denied because Mr. Mitchell’s injury and/or illness occurred as the result of an on-the-job injury.” Additionally, the letter went on to explain that “[t]his construction-related injury is covered pursuant to the Tennessee Workers’ Compensation Act, and is therefore, not covered by the DCI Medical Benefits Plan.” J.A. at 225. According to the Mitchells, Mr. Hagewood only reached this decision because he was advised to by DCFs attorneys at the law firm of Bass, Berry & Sims, which, they claim, represents DCI in litigation matters. As evidence, the Mitchells point to a letter from the firm advising Mr. Hagewood that it believed Mr. Mitchell’s expenses were not covered by the Plan and attaching a letter for Mr. Hagewood to sign and send to Mrs. Mitchell explaining why the Plan was denying benefits. See J.A. 320-21. The letter contains the same language as [352]*352that Mr. Hagewood sent to Mrs. Mitchell on October 8.

Mrs. Mitchell appealed Mr. Hagewood’s decision. On December 17, 1998, the Plan denied the appeal.

The Mitchells filed this action.

Plaintiffs claim that since Mr. Mitchell was self-employed as an independent contractor and had no worker’s compensation insurance, that he was covered by Mrs. Mitchell’s policy. They rely on the language of the “Medical Exclusions and Limitations” section of the Plan which provides:

No benefits will be payable under the Plan for the following:
❖ ❖ i'fi
5. Charges which result from any Accidental Bodily Injury or any Illness which arises out of, or in the course of employment with any employer for which the covered person is entitled to benefits under any Worker’s Compensation Law.

DCI moved for summary judgment on the ground that the plain language and the administrator’s reasonable interpretation of the Plan excludes coverage for Mr. Mitchell’s injuries.

The Benefit Description of the Plan provides:

Non-Occupational Coverage
Unless otherwise specified, the accident and health coverage provided under this Plan is non-occupational and any reference to “illness” or “injury” in the following benefit sections means only a non-occupational illness or injury. Non-Occupational Illness is one which does not arise of (or in the course of) any work for pay or profit, nor in any way results from an illness which does. However, if proof is furnished to the Plan administrator that an individual covered under a Worker’s Compensation Law (or other law of similar purpose), is not covered for a particular illness under such law, that illness shall be considered “non-occupational” regardless of its cause.
Non-Occupational Injury is one which is an accidental bodily injury and does not arise out of (or in the course of) any work for pay or profit, nor in any way results from an injury which does.

The district court agreed that there was no coverage. It acknowledged that there was more than one plausible interpretation of the exclusion on which plaintiffs rely but under the deferential standard, it could not find the Plan’s interpretation arbitrary or capricious especially in view of the Benefits Description language which clearly states there is no coverage for job-related injuries. The Mitchells appeal that decision.

II.

On appeal, the Mitchells argue that the district court erred because (1) its interpretation of the exclusion provision is not supported by the provision’s plain language, (2) it failed to construe any ambiguities against the drafters, and (3) it failed to take account of DCI’s conflict of interest.

Because much of the argument goes to the issue of the standard of review, we begin there.

A.

While the standard of review of the district court’s decision is de novo, it is very deferential for the Plan administrator’s decision. Where, as here, the Plan gives the administrator of the Plan discretionary authority to determine eligibility for benefits or to construe the terms of the Plan, this court reviews the administrator’s decision only to determine whether she [353]*353acted arbitrarily or capriciously in denying benefits.

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Bluebook (online)
18 F. App'x 349, Counsel Stack Legal Research, https://law.counselstack.com/opinion/mitchell-v-dialysis-clinic-inc-ca6-2001.