Nichols v. Wal-Mart Stores, Inc. Associates' Health & Welfare Plan

259 F. Supp. 2d 1213, 2003 U.S. Dist. LEXIS 12040, 2003 WL 1989566
District Court, D. Utah·Decided March 26, 2003·No. 2:00-cv-00010·Published

Opinion

MEMORANDUM OPINION AND ORDER GRANTING PARTIAL SUMMARY JUDGMENT AND REMANDING FOR FURTHER PROCEEDINGS

CASSELL, District Judge.

This matter is before the court on cross-motions for summary judgment. The essence of the dispute is over whether the plaintiff, Amy Nichols, was entitled to insurance coverage under defendant Wal-Mart’s Health and Welfare plan for procedures that occurred at the end of her pregnancy. The court held a hearing on this matter and requested supplemental briefing from the parties. Being fully advised, the court grants partial summary judgment for Ms. Nichols and remands for further proceedings.

*1215 FACTUAL BACKGROUND

Amy Nichols was a beneficiary of the Wal-Mart Associates’ Health and Welfare Plan (the “Plan”) and eligible for benefits under the Plan. Ms. Nichols’s husband Tory was a Wal-Mart employee in May of 1995. The Plan is a group medical benefits plan sponsored by Wal-Mart Stores, Inc., for the benefit of its employees and their dependents. The Plan is self-funded, and the Administrative Committee of the Plan (the “Committee”) was the plan administrator. The Committee was the named fiduciary of the Plan. Wal-Mart Stores, Inc. sponsors the Plan, and pays the plan administrator.

Medical History

In mid-December 1994, Ms. Nichols became pregnant. At 17/6 weeks, Dr. Geral Mortimer (Ms. Nichols’s obstetrician) performed an ultrasound that demonstrated poor visualization of the fetus such that the fetal sex could not be determined.

On May 17, 1995, Dr. Mortimer performed another ultrasound which caused him concern because of ogliohydramnios. Ogliohydramnios is a deficiency of amniotic fluid sometimes resulting in an embryonic defect through adherence between embryo and amnion. Dr. Mortimer referred Ms. Nichols to the University of Utah Medical Center (UUMC), in Salt Lake City, for additional testing.

On May 19, 1995, Ms. Nichols had an abnormal obstetrical sonogram at UUMC which showed that the fetal size was equivalent to 22.7 weeks. Multiple cysts were seen on both fetal kidneys. No definite fetal bladder of amniotic fluid was seen. The fetus had bilateral mulitcystic [poly-cystic] dysplastic kidneys indicating abnormal growth or development of the kidneys. Plycystic kidney disease can be either one of two hereditary diseases characterized by gradual enlarging bilateral cysts of the kidney which lead to reduced renal function. It is a disease that is inherited as an autosomal recessive trait. It usually affects infants or children and results in renal failure. Ms. Nichols was not admitted to the UUMC at this time. Instead, she returned home.

On May 24, 1995, at approximately 23]4 weeks into her pregnancy, Ms. Nichols was admitted to UUMC and treated for complications in her pregnancy. Ms. Nichols’ diagnosis upon admission was for fatal fetal anomalies, premature rupture of membranes, and breech presentation. An amniotic infusion was attempted at UUMC, but this attempt failed. The fetus had “grave and fatal fetal anomalies” and was non-viable. Ms. Nichols consulting with her husband and her physician. She also consulted her uncle- — Dean of the University of Florida College of Medicine — as to the best course of action for Ms. Nichols and her baby. Her uncle confirmed the lethality of the condition to both mother and baby. Based on these consultations, the decision was made to induce labor due to grave fetal anomalies.

At 2:53 a.m. on May 25, 1995, Matthew Lynn Nichols was born still born. He weighed 700 grams and had Apgar scores of zero, one minute after birth, and zero, five minutes after birth. There were no contractions or fetal heart monitoring. An autopsy was performed and the cause of Matthew’s death was determined to be intrauterine fetal demise, fatal fetal poly-cystic dysplastic kidneys, and bilateral severe ogliohydramnios.

Plan Language

The Plan specified generally what procedures it would cover and those it would not. Specifically, the plan stated:

Pregnancy
The benefit for expenses due to pregnancy, including birthing centers, licensed doctors, nurses, or midwives operating under state guidelines, is eligible *1216 for payment the same as for any other illness, after the services are performed.
Hospital Expenses -
For each hospital confinement, whether inpatient or outpatient, your Medical coverage will pay for the following eligible hospital expenses for the described limits:
Room and Board — Charge for room and board will be allowed at the prevailing semi-private room rate. In the event the institution has only private rooms, 90% of the hospital’s lowest private room rate for the hospital will be covered.
Intensive Care, Cardiac Care, and Other Critical Care
Other Hospital Services — -Expenses incurred for services and supplies furnished by the hospital for medical care such as operating room, x-ray, laboratory tests, medicines, etc., administration of anesthetics, and local ambulance service.
Other Covered Expenses
Doctors’ Services
Charges Not Covered
Benefits shall not be payable for treatment or services for the following: Charges for, or relating to, any treatment or . service for abortions, sexual dysfunction, infertility, birth control, sex transformations, sterilization or reversal of sterilization procedures, artificial in-seminations, in-vitro fertilizations or embryo transfers, and any complications arising therefrom (whether or not a doctor indicates medical necessity).
Charges for routine ultrasounds for pregnancy.
Charges for elective (non-emergency), (non-urgent) hospital confinements outside the United States without prior approval.

The Plan further outlined the plan participant’s rights under the Employee Retirement Income Security Act of 1974 (ERISA). It stated:

... plan participants shall be entitled to:
1. Examine, without charge, at the Plan Administrator’s office, all plan documents including insurance contracts, collective bargaining agreements and copies of all documents filed by the plan with the U.S. Department of Labor, such as detailed annual reports and plan descriptions.
2. Obtain copies of all plan documents and other plan information upon written request to the Plan Administrator. The Plan Administrator may make a reasonable charge for the copies.

Claims Process

On May 25, 1995, Marj Brown, an employee of UUMC, spoke to Jamie Pender-graft, an employee of the Plan to obtain insurance benefit verification for Ms. Nichols. Ms. Pendergraft indicated that UUMC was a network facility.

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Nichols v. Wal-Mart Stores, Inc. Associates' Health & Welfare Plan, 259 F. Supp. 2d 1213, 2003 U.S. Dist. LEXIS 12040, 2003 WL 1989566 (D. Utah 2003).

259 F. Supp. 2d 1213 (Nichols v. Wal-Mart Stores, Inc. Associates' Health & Welfare Plan) — published by Counsel Stack Legal Research, free access to 12M+ legal documents.

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