Nazay v. Miller

768 F. Supp. 124, 14 Employee Benefits Cas. (BNA) 1108, 1991 U.S. Dist. LEXIS 9032, 1991 WL 144104
CourtDistrict Court, M.D. Pennsylvania
DecidedApril 19, 1991
DocketCiv. A. No. 1: CV-90-1641
StatusPublished
Cited by2 cases

This text of 768 F. Supp. 124 (Nazay v. Miller) is published on Counsel Stack Legal Research, covering District Court, M.D. Pennsylvania primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Nazay v. Miller, 768 F. Supp. 124, 14 Employee Benefits Cas. (BNA) 1108, 1991 U.S. Dist. LEXIS 9032, 1991 WL 144104 (M.D. Pa. 1991).

Opinion

MEMORANDUM

CALDWELL, District Judge.

The plaintiff, Richard Nazay, Sr., a retired employee of Bethlehem Steel Corporation (Bethlehem), brought this action under the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. § 1001 et seq., to recover for the partial denial of hospitalization benefits under Bethlehem’s health insurance plan for retirees. The action had been filed before a Pennsylvania District Justice but was removed to this court by the defendants, L. Miller, a Bethlehem employee at its Steelton plant involved in insurance matters, Michael P. Dopera, the Secretary of the Insurance Board under the Social Insurance Plan of [126]*126Bethlehem Steel Corporation and Subsidiary. Companies, and Bethlehem. We have jurisdiction pursuant to 29 U.S.C. §§ 1132(a)(1)(B) and 1132(e).

We are currently considering the defendants’ motion for summary judgment and what the plaintiff has styled his “counterclaim for summary judgment.” These cross-motions will be evaluated under the well established standard. See Williams v. Borough of West Chester, 891 F.2d 458 (3d Cir.1989).

The facts are not in dispute. For many years Nazay has had a bad heart and in the months prior to his hospitalization in June of 1989, he was experiencing shortness of breath. The plaintiff consulted two physicians who determined that he had to be hospitalized for treatment with a drug which would strengthen his heart muscle. Plaintiff was in the hospital from June 22, 1989, to June 29, 1989. The bill came to $7,438.39.

It was subsequently submitted for payment to Bethlehem’s health insurance plan for pensioners, a welfare benefit plan within the meaning of ERISA. The treatment was found to be medically necessary and there was no dispute about the amount of the charges but the Insurance Board refused to pay the entire bill. It deducted $2231.51, thirty per cent, because plaintiff had failed to obtain precertification of the hospital stay in violation of the following provision of the insurance plan.1 Captioned “Precertification Procedures and Concurrent Utilization Review,” it provides, in relevant part, as follows:

Whenever you ... are to be admitted as an inpatient on a non-emergency basis to a Hospital ... a precertification request must be processed prior to the admission....
If you are admitted to any facility requiring preeertification on an emergency basis, the certification process must begin within 48 hours of the admission (or as soon as reasonably practical under the circumstances) unless such requirement is waived by the Plan Administrator.
If you fail to obtain precertification or certification as described above and the admission or services rendered are determined to have been medically necessary, a penalty of an additional 30% of the Covered Expenses will be applied.
If you fail to obtain precertification or certification as described above and the admission or services rendered are determined to have been not medically necessary, the admission or services rendered will be considered non-covered expenses and any charges incurred will be your responsibility.

(Summary Plan Description at p. 28, attached to the affidavit of Charles F. Collins) (emphasis in original).

The rule was adopted to reduce the risk of unnecessary medical care by allowing the Insurance Board to review proposed care before it takes place. The defendants therefore argue that the penalty cannot be considered arbitrary or capricious, the standard the defendants would apply to the Board’s decision in light of the plan’s delegation of authority “to interpret and construe the provisions of the Plan ... and to decide such questions as may arise in connection with the operation of the Plan.” (Summary Plan Description, 11 2.28 at p. 47). See Stoetzner v. United States Steel Corp., 897 F.2d 115 (3d Cir.1990).

The plaintiff does, not contest the application of this standard to the Board’s decision at issue in the instant case. We will not make an issue of it either, since it appears that the Board’s action cannot be justified even under this lenient standard of review.

The plaintiff’s position is that the precer-tification penalty requirement violates “public policy” by arbitrarily and capriciously imposing a 30% penalty for what the defendants concede was medically necessary treatment. Plaintiff argues that the penalty is excessive and that it does not serve the Board’s stated goal because the Board has the authority in any event to [127]*127refuse to pay unnecessary medical costs. Thus, the penalty only serves to deprive plan participants of coverage to which they are entitled.2

The plaintiffs public policy argument fairly encompasses a claim that the Board’s imposition of a penalty violates the fiduciary duties imposed upon it by ERISA pursuant to 29 U.S.C. § 1104(a)(1). That section provides, in pertinent part, as follows (brackets added):

[A] fiduciary shall discharge his duties with respect to a plan solely in the interest of the participants and beneficiaries and—
(A) for the exclusive purpose of:
(i) providing benefits to participants and their beneficiaries;
(ii) defraying reasonable expenses of administering the plan....

The parties have not cited any cases dealing with the issue in the instant case nor have we been able to locate any cases construing precertification clauses under ERISA. We believe, however, that Northeast Department ILGWU Health And Welfare Fund v. Teamsters Local Union No. 229 Welfare Fund, 764 F.2d 147 (3d Cir.1985), provides some guidance on how to dispose of the parties’ cross-motions.

In Northeast, the issue was which of two union benefit plans was responsible for the claimant’s medical bills when both arguably provided coverage. Each plan had incompatible “other insurance” provision. One of the provisions was known in insurance law as an escape clause and the other as an excess clause. In determining how to coordinate the enforcement of these clauses under ERISA, the Third Circuit examined how state courts dealt with the issue under state insurance law. The court concluded that the majority of state courts would not enforce an escape clause as against an excess clause. It then determined whether the majority rule should be applied to an ERISA plan, having already concluded that a clause which conflicts with ERISA cannot be enforced. In making this second determination, the court noted generally that “ERISA is a comprehensive statutory scheme designed to protect employees enrolled in pension and benefit plans,” id.

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Related

Nazay v. Miller
949 F.2d 1323 (Third Circuit, 1991)

Cite This Page — Counsel Stack

Bluebook (online)
768 F. Supp. 124, 14 Employee Benefits Cas. (BNA) 1108, 1991 U.S. Dist. LEXIS 9032, 1991 WL 144104, Counsel Stack Legal Research, https://law.counselstack.com/opinion/nazay-v-miller-pamd-1991.