Noah U. v. Tribune Co. Medical Plan

138 F. Supp. 3d 1134, 2015 U.S. Dist. LEXIS 142499
CourtDistrict Court, C.D. California
DecidedOctober 7, 2015
DocketCASE NO. 2:14-CV-03062-SVW-AJW
StatusPublished
Cited by1 cases

This text of 138 F. Supp. 3d 1134 (Noah U. v. Tribune Co. Medical Plan) is published on Counsel Stack Legal Research, covering District Court, C.D. California primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Noah U. v. Tribune Co. Medical Plan, 138 F. Supp. 3d 1134, 2015 U.S. Dist. LEXIS 142499 (C.D. Cal. 2015).

Opinion

ORDER DETERMINING THE STANDARD OF REVIEW AND DENYING PLAINTIFF’S MOTION TO STRIKE TRIBUNE’S 2012 PLAN [53]

STEPHEN V. WILSON, United States District Judge

I. INTRODUCTION

Plaintiff Noah U.1 brought this case against his insurer, defendant Tribune Company Medical Plan (“the Plan”), after his insurance claim for treatment of his eating disorder was denied. The Court-is presently called upon to decide the applicable standard of review. Also before the Court is Plaintiffs motion to strike the 2012 Plan document pursuant to Federal Rule of Civil Procedure 37. (Dkt.53.) For the reasons discussed below, the Court DENIES Plaintiffs motion and determines that the dé- novo standard of review applies to Plaintiffs case.'

II. BACKGROUND2

A. TKé 2012 Plan

The Tribune Company (“Tribune”) maintains the Tribune Company Group Welfare Benefits Plan (the “Plan”) to provide health and welfare benefits to eligible employees. (Dansart Deck, Ex. 1, at TRIBUNE0Q169.) The 2012 Plan document (the “2012 Plan”) provides that though the Plan is administered by Tribune, certain Participating Benefits are administered by an insurance company or other outside entity. (Id. at TRIB-UNEÓ0170.) It further states that documents and notices' required to be filed with the Plan shall be given to the Plan Administrator in care of Tribune, unless, the document or notice is required by a Participating Benefit that is administered by an insurance company or other outside entity. For Participating Benefits administered by an insurance company or other outside entity, notices and documents shall be delivered to “the plan administrator listed in the' Participating Benefit Documents incorporated by reference in the applicable Participating Benefit’s Plan Supplement.” (Id.)

[1138]*1138The 2012 Plan defines a “Plan Administrator” as the “Employee- Benefits Committee or its designee as specified irnthe applicable Participating Benefit.” (Id. at TRIBUNE00178.) It defines a “Claims Administrator” as “a person or persons, or entity or entities, appointed by the Plan Administrator to serve as the Claims Administrator for a given Participating Benefit.” (Id. at TRIBUNE00174.) The 2012 Plan further provides that:.

Each Claims Administrator shall have the responsibility for review and payment of claims and recordkeeping related thereto and, to the‘.extent directed by the Company and as set forth in the applicable Participating Benefit’s documents listed and incorporated by reference in the applicable Plan Supplement, may have authority to exercise its discretion with respect to the initial determination of benefits under the Participating Benefit, and certain appeals of denied benefit claims under such Participating Benefit. The Claims Administrator for each Participating Benefit and the Claims Administrator’s responsibilities are set forth in the Participating Benefit’s documents as listed and incorporated by reference in the applicable Plan Supplement.

(Id. at TRIBUNE00174-75) (empliasis added).

The 2012 Plan defines an “Appeals Fiduciary” as a person or entity “torwhom the Plan Administrator has delegated the fiduciary duty and authority to exercise discretion in the review and resolution of any appeal of a denied claim.” (Id. at TRIB-UNE00173.) The 2012 Plan states that the “Appeals Fiduciaries for appealing a denied claim under each Participating Benefit are set forth in the Participating Behefit’s participating documents as listed and incorporated by reference in the applicable Plan Supplement.” (Id.)

In the “Claims Procedure” section, under item 6.2—Claims Procedure for ERISA Participating Benefits, the 2012 Plan states:

The Plan Administrator has delegated claims and appeals responsibilities to Claims Administrators and Appeals Fiduciaries. The designated Claims Administrators and Appeals Fiduciaries are responsible for evaluating all claims and benefits under the Plan.... Benefits shall be paid under the Plan only if the Claims Administrators or Appeals Fiduciaries determine in their discretion that the claimant is entitled to them.

(Id. at TRIBUNE00189) (emphasis added).

In the “Administration of the Plan” section, the 2012 Plan states that the Plan Administrator and any representative that it designates pursuant to that section “shall have the discretionary authority to administer the Plan as specified herein.” (Id. at TRIBUNE00211.) The document enumerates the Plan Administrator’s powers and duties, which include, inter alien:

(i) To construe and interpret the terms of the Plan and to determine all questions arising under the Plan, including the power to determine the rights or eligibility of Eligible Employees or Dependents under the Plan and Participating Benefits and the amount, manner, and timing of their benefits hereunder, and to remedy ambiguities, inconsistencies, and omissions.
(viii) To employ agents, attorneys, accountants, actuaries, or other persons and allocate or delegate them such powers, rights and duties as the Plan Administrator may consider necessary or desirable to properly carry out the administration of the Plan, provided that süeh allocation or delegation, and the [1139]*1139acceptance thereof ... shall be in writing.

(Id. at TRIBUNE00211-12.)

The Plan Administration section further provides that the Plan Administrator “may designate other organizatipns or persons ... to carry out specific fiduciary or non-fiduciary responsibilities of the Plan Administrator” including but not limited to:

(i) Pursuant to the terms of an administrative services agreement or claims administration agreement, the responsibility for administering and managing any part of the Plan, including the processing and payment of claims under the Plan and recordkeeping related thereto;
(iii) The responsibility to review claims or claim denials under the Plan to the extent an insurer, Claims Administrator, or Appeals Fiduciary is not empowered with such responsibility under the terms of the Plan or under the terms of any insurance policy or contract identified in the applicable Plan Supplement.

(Id. at TRIBUNE00212.)

The 2012 Plan states that “[supplements are attached to and form a part of the Plan for purposes of incorporating by reference the terms and provisions of the Participating Benefits.” (Id. at TRIB-UNE00171.) It also states that supplements may occasionally be added or modified. (Id. at TRIBUNE00171-72.) The 2012 Plan further states that:

A Participating Benefit, as identified in the applicable Plan Supplement, is documented by a Summary Plan Description (‘SPD’), an insurance policy and certificate of coveragé, or membership booklet. The documentation for each Participating Benefit is identified and incorporated by reference in the Plan through Plan Supplements.

(TRIBUNE00171.)

In contrast to the documents that the 2012 Plan expressly incorporates, it provides that:

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Cite This Page — Counsel Stack

Bluebook (online)
138 F. Supp. 3d 1134, 2015 U.S. Dist. LEXIS 142499, Counsel Stack Legal Research, https://law.counselstack.com/opinion/noah-u-v-tribune-co-medical-plan-cacd-2015.