Overcash v. Blue Cross & Blue Shield

381 S.E.2d 330, 94 N.C. App. 602, 1989 N.C. App. LEXIS 631
CourtCourt of Appeals of North Carolina
DecidedJuly 18, 1989
Docket8819SC1047
StatusPublished
Cited by19 cases

This text of 381 S.E.2d 330 (Overcash v. Blue Cross & Blue Shield) is published on Counsel Stack Legal Research, covering Court of Appeals of North Carolina primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Overcash v. Blue Cross & Blue Shield, 381 S.E.2d 330, 94 N.C. App. 602, 1989 N.C. App. LEXIS 631 (N.C. Ct. App. 1989).

Opinion

PARKER, Judge.

I.

This action arises out of an alleged breach of an insurance contract. Plaintiff’s decedent was a beneficiary of a group medical insurance contract issued by defendant. Decedent suffered from systemic amyloidosis, a progressive, chronic disease that affects several internal organs. Decedent’s condition began to deteriorate in the spring of 1986. At first, her family was able to care for her at home with weekly visits from a nurse. On 4 August 1986, *605 decedent was hospitalized on account of her increased weakness and inability to eat. Decedent was discharged from the hospital on 15 August 1986. At that time, decedent’s physician felt that her condition had deteriorated to the point where she required twenty-four hour nursing care. After consulting with the physician, decedent’s family decided to obtain home nursing care for decedent,

Decedent remained under twenty-four hour home nursing care until 9 January 1987 when she was again hospitalized. She was discharged on 15 January 1987 and resumed treatment at home. She died on 12 March 1987.

Defendant provided coverage for nursing services rendered prior to the August 1986 hospitalization and subsequent to the January 1987 hospitalization. Defendant denied coverage, however, for home nursing services rendered from 15 August 1986 to 9 January 1987. Plaintiff filed a complaint in which he stated causes of action based on breach of contract, unfair and deceptive trade practices, and violations of the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. §§ 1001 et seq. Plaintiff sought compensatory and punitive damages, treble damages pursuant to G.S. 75-16, and attorney’s fees. Defendant filed an answer, asserted a counterclaim for attorney’s fees under ERISA, and moved to strike plaintiff’s request for a jury trial as to the causes of action arising under ERISA.

Both parties filed motions for partial summary judgment. On 19 April 1988, Judge Robert A. Collier, Jr. entered an order finding that the action was governed by ERISA, dismissing plaintiff’s claims based upon State law, granting summary judgment for plaintiff on his claim under ERISA for payment of benefits, denying defendant’s motion to strike plaintiff’s demand for jury trial, and reserving for trial plaintiff’s remaining claims under ERISA for extra-contractual and punitive damages. The matter came on for hearing before Judge James C. Davis on 24 May 1988. Judge Davis determined that plaintiff was entitled to $37,757.08 in attorney’s fees and costs and so ordered in open court whereupon plaintiff gave notice that he was voluntarily dismissing all remaining claims. On 1 June 1988, defendant filed both a notice of appeal from the 24 May order and a motion for attorney’s fees pursuant to ERISA and Rule 11 of the N.C. Rules of Civil Procedure. In response, plaintiff filed a motion for sanctions pursuant to Rule 11. On 15 August 1988, Judge Julius A. Rousseau, Jr. entered an order deny *606 ing defendant’s motion and awarding plaintiff $500.00 under Rule 11 for the expense of defending against defendant’s motion.

Defendant appeals from the trial court’s entry of summary judgment for plaintiff in the amount of $40,419.80, the court’s award of attorney’s fees and costs to plaintiff in the amount of $37,757.08, and the court’s award of $500.00 to plaintiff as sanctions under Rule 11. Defendant contends that each of these actions was error and further asserts that should this Court reverse plaintiff’s summary judgment, plaintiff is not entitled to jury trial on his claim for benefits. Defendant also contends the court erred in denying defendant’s motion for attorney’s fees pursuant to ERISA and Rule 11.

II.

Before determining the merits of defendant’s' appeal, we must clarify the law governing plaintiff’s claims. The trial court found that this action was governed by ERISA rather than State law. Plaintiff filed a notice of appeal which specifically addressed this point but abandoned his appeal. In his brief, however, plaintiff states that he abandoned his appeal only out of concern for the complexity of the case on appeal, but he does not concede that the action is controlled by ERISA. We cannot review the trial court’s actions in this case without first determining whether the court applied the correct law to plaintiff’s claims.

Subject to certain well-defined exceptions, ERISA covers any “employee benefit plan” which is established or maintained by an employer or an employee organization. 29 U.S.C. § 1003. The definition of “employee benefit plan” includes medical insurance plans. 29 U.S.C. § 1002(1), (3). Although the exact details of the group insurance plan at issue in this case are unclear, the record does show that the plan was maintained by plaintiff, who was decedent’s husband, to provide insurance for employees of businesses he owned. Therefore, the plan is subject to the provisions of ERISA.

Under ERISA, a beneficiary of a covered plan may bring a civil action to obtain several types of relief. 29 U.S.C. § 1132(a). Jurisdiction of civil actions is vested exclusively in the federal courts with the exception of actions under subsection (a)(1)(B) of 29 U.S.C. § 1132, for which jurisdiction is concurrent in state and federal courts. 29 U.S.C. § 1132(e)(1). Subsection (a)(1)(B) of the statute provides that a beneficiary may bring an action “to recover *607 benefits due to him under the terms of his plan, to enforce his rights under the terms of the plan, or to clarify his rights to future benefits under the terms of the plan.” The claim on which plaintiff obtained summary judgment was a claim for benefits due. Therefore, the trial court could properly exercise its jurisdiction over that claim.

III.

Having determined that plaintiff’s claim for benefits is within the scope of ERISA, we proceed to consider whether the trial court erred in entering summary judgment in plaintiff’s favor.

A.

We begin by noting that the provisions of ERISA pre-empt all state laws that “relate to any employee benefit plan.” 29 U.S.C. § 1144(a). The pre-emption includes state decisional law as well as statutes. 29 U.S.C. § 1144 (c). ERISA also pre-empts state common-law contract and tort actions. Pilot Life Ins. Co. v. Dedeaux, 481 U.S. 41, 107 S.Ct. 1549, 95 L.Ed. 2d 39 (1987). The civil enforcement provisions of ERISA are exclusive and are governed by federal substantive law. Id. at 54-56, 107 S.Ct.

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Bluebook (online)
381 S.E.2d 330, 94 N.C. App. 602, 1989 N.C. App. LEXIS 631, Counsel Stack Legal Research, https://law.counselstack.com/opinion/overcash-v-blue-cross-blue-shield-ncctapp-1989.