Mondry v. American Family Mutual Insurance

497 F. App'x 603
CourtCourt of Appeals for the Seventh Circuit
DecidedNovember 28, 2012
DocketNos. 10-3409, 11-1750
StatusPublished
Cited by4 cases

This text of 497 F. App'x 603 (Mondry v. American Family Mutual Insurance) is published on Counsel Stack Legal Research, covering Court of Appeals for the Seventh Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Mondry v. American Family Mutual Insurance, 497 F. App'x 603 (7th Cir. 2012).

Opinion

ORDER

In these consolidated appeals, Sharon Mondry challenges both the damages and the fees awarded to her in this suit filed under the Employee Retirement Income Security Act (“ERISA”), 29 U.S.C. § 1132. Finding no clear error or abuse of discretion in any of the district court’s determinations, we affirm.

I.

Mondry worked for American Family Mutual Insurance Company (“American Family”) until September 2003. She participated in the AmeriPreferred PPO Plan (the “Plan”), a self-funded group health plan that American Family offered to its employees. During the time period relevant to this litigation, American Family had contracted with Connecticut General Life Insurance Company through its affiliates (collectively, “CIGNA”) to act as the Plan’s third-party claims administrator, meaning that CIGNA would handle any and all benefit claims against the Plan.

Mondry’s son Zev, whom she had enrolled as a Plan beneficiary, required speech therapy. Initially, he received that therapy through Wisconsin’s Birth to Three program for infants and toddlers with developmental delays and disabilities. When Zev aged out of that program, Mon-dry arranged for him to continue his speech therapy at the Communication Development Center (“CDC”) beginning in January 2003. CDC in turn submitted invoices to the Plan seeking reimbursement for the services it provided to Zev.

CIGNA denied the claim for reimbursement, reasoning that Zev’s speech therapy was not a medically necessarily service covered by the terms of the Plan. In its correspondence with Mondry denying her original claim and then her first-level appeal, CIGNA cited two documents as au[605]*605thoritative: CIGNA’s Benefit Interpretation Resource Tool for Speech Therapy (“BIRT”), and CIGNA’s Clinical Resource Tool for Speech Therapy (“CRT”). Neither of these was a document setting forth the terms of the AmeriPreferred Plan and, as it turned out, both were inconsistent with the governing terms of the Plan. In the end, CIGNA realized its error and belatedly granted Mondry’s claim for benefits. But that occurred only after Mon-dry’s counsel succeeded in obtaining copies of these documents; and due in large part to CIGNA’s intransigence, that task took an exceedingly long time to accomplish (two years to reverse the initial denial of benefits, and more than four years to be reimbursed completely for her out-of-pocket costs).

Pursuant to 29 U.S.C. § 1024(b)(4), American Family had a duty to produce Plan documents to Mondry within thirty days of her request. After she finally succeeded in obtaining benefits from CIG-NA, Mondry sued both it and American Family for violation of section 1024(b)(4). She also separately alleged that both defendants violated their fiduciary duties to her as a Plan participant by withholding from her the key documents — in particular, the BIRT and CRT — that she needed to prevail in her quest for benefits under the Plan. See 29 U.S.C. § 1104(a)(1).

In our prior decision, we sustained Mon-dry’s claims in part. Mondry v. Am. Family Mut. Ins. Co., 557 F.3d 781 (7th Cir.2009) (“Mondry I ”). We agreed with Mondry that, under the unique circumstances of her case, CIGNA’s express reliance on the BIRT and CRT effectively rendered those two internal documents Plan documents that were subject to timely production pursuant to section 1024(b)(4). We were willing to assume that CIGNA’s private reliance on such internal tools would not have brought them within the relatively small universe of tools that we and other courts had deemed to be documents that must be produced to a participant on demand. 557 F.3d at 799. We cited a substantial line of cases to that effect, including the First Circuit’s decision in Doe v. Travelers Ins. Co., 167 F.3d 53, 60 (1st Cir.1999). Mondry, 557 F.3d at 797-800. But because CIGNA had expressly cited those documents as authoritative to Mondry, and indeed had quoted language from one of them (the BIRT) in explaining why it believed Zev’s speech therapy was not compensable, CIGNA had effectively rendered those tools documents which governed the operation of the Plan. Id. at 799-800. We also held that the claims administration agreement between American Family and CIGNA qualified as a Plan document, in the sense that it defined their respective obligations vis-a-vis the divided administration of the Plan. Id. at 796. However, we noted that only American Family, as the Plan administrator, bore the duty to produce Plan documents under section 1024(b)(4). Id. at 793-95. CIGNA may have had sole possession of the BIRT and CRT, but the liability for the failure to produce such documents fell upon American Family alone; and we were not convinced that it was beyond American Family’s power to obtain access to such documents. Id. at 801-03. Separately, we concluded that American Family could additionally be liable to Mondry for breaching the fiduciary duty it owed to her in its role as the Plan administrator — specifically for the lost time value of the money Mondry was forced to spend out of pocket on her son’s speech therapy until she finally obtained copies of the CRT and BIRT and was able to prevail in her appeal of CIGNA’s denial of her claim for benefits. Id. at 803-09; see 29 U.S.C. § 1104(a)(1). We remanded to the district court with directions to enter summary judgment in favor of Mondry [606]*606on the section 1024(b)(4) document production claim and to determine an appropriate penalty under 29 U.S.C. § 1132(c)(1). 557 F.3d at 809. We further directed the court to conduct a trial on whether American Family had breached its fiduciary obligation to Mondry by failing to comply with section 1024(b)(4). Id.

On remand, the district court complied with our mandate and, after conducting a two-day trial, awarded statutory damages of $9,270 to Mondry for American Family’s failure to timely produce Plan documents to her; and after finding that American Family had breached the fiduciary duty it owed to Mondry, the court awarded her stipulated damages of $603.25 for that breach. R. 139. In calculating the award of statutory damages, the court determined that daily penalties for the failure to produce a Plan document did not begin to accumulate until Mondry and her counsel placed American Family on notice that she was seeking that particular document. With respect to the CRT, the court found that a specific reference to that document in an October 30, 2003 letter from Mondry’s counsel to CIGNA, on which American Family was copied, triggered American Family’s duty to produce that document and rendered American Family liable for daily penalties beginning thirty days after that request. Id. at 20-21. Counting forward from November 30, 2004, a total of 215 days passed before Mondry obtained a copy of the CRT. Id. at 21. As to the BIRT, the court deemed an April 21, 2004 fax from Mondry’s counsel to American Family’s counsel sufficient to place American Family on notice that she was seeking that particular interpretive tool. Id. at 21-22.

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Bluebook (online)
497 F. App'x 603, Counsel Stack Legal Research, https://law.counselstack.com/opinion/mondry-v-american-family-mutual-insurance-ca7-2012.