Pittard v. Watkins Associated Industries, Inc.

990 F. Supp. 1444, 1997 U.S. Dist. LEXIS 21226, 1997 WL 817319
CourtDistrict Court, N.D. Georgia
DecidedSeptember 30, 1997
Docket1:96-cv-01197
StatusPublished
Cited by2 cases

This text of 990 F. Supp. 1444 (Pittard v. Watkins Associated Industries, Inc.) is published on Counsel Stack Legal Research, covering District Court, N.D. Georgia primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Pittard v. Watkins Associated Industries, Inc., 990 F. Supp. 1444, 1997 U.S. Dist. LEXIS 21226, 1997 WL 817319 (N.D. Ga. 1997).

Opinion

ORDER

FORRESTER, District Judge.

This action, brought under the Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1001, et seq. (“ERISA”), is before the court on a variety of procedural and dispositive motions.

I. STATEMENT OF CASE

A. Statement of Facets

1. The Plan and the Benefits Under the Plan

Defendant Watkins Associated Industries, Inc. Group Life Insurance and Health Protection Plan (the “Plan”) is an employee welfare benefit plan as defined in Section 3(1) of ERISA, 29 U.S.C. § 1002(1). The Plan provides medical expense reimbursement to eligible employees of Defendant Watkins Associated Industries, Inc. (“Watkins’,’), and its subsidiaries. The Plan and the benefits provided under the Plan are funded by a trust maintained pursuant to the Plan. Watkins and its subsidiaries and the participating employees make fixed monthly contributions to the Plan’s trust. All funds held in the Plan’s trust are applied solely for the benefit of the covered employees, under the Plan, and the Trust document forbids any reversion of assets held in the Trust to the Plan sponsor or any subsidiary thereof. The Plan is maintained pursuant to a plan document that includes a Summary Plan Description. 1 Although the Plan does not include the Summary Plan Description and does not expressly incorporate by reference the Summary Plan Description into the Plan, 2 the Summary Plan Description contains the written terms of medical reimbursement coverage provided under the Plan. In particular, the Summary Plan Description includes a provision that states:

Any medical or dental condition for which a Participant was treated or has symptoms before the Participant’s effective date will be excluded from coverage under this Plan for one year after the initial eligibility date. A diagnosis of the condition is not required, only the existence of treatment or symptoms.
2. Plaintiffs Medical Claim Under the Plan

Plaintiff Richard Pittard (“Plaintiff”) became employed by .Tucker Door and Trim Corporation on January 11, 1993, and he became eligible for coverage under the Plan one month later on February 11, 1993. At the time he began working, Plaintiff received a copy of the Summary Plan Description.

In November of 1993, Plaintiff experienced symptoms of shortness of breath and chest tightness upon exertion. 3 Plaintiff’s cardiologist, Dr. Shonkoff, diagnosed Plaintiff with *1447 critical aortic stenosis in Ms bicuspid aortic valve. On December 1, 1993, Dr. Langford performed surgery on Plaintiff to replace the stenotic bicuspid aortic valve. The discharge summary, which was dictated by Kenneth L. Norris, P.A., listed Plaintiffs admitting diagnosis as “aortic valve disorder” and the principal diagnosis as “congemtal aortic valve insufficiency.” Following Plaintiffs surgery, claims were submitted to the Plan by Plaintiffs physician and hospital totaling $50,300, and were ultimately denied based upon the pre-existing condition clause in the Summary Plan Description.

Aortic stenosis is a degenerative disease that causes a narrowing of the aortic valve, usually over a period of many years. Although it is disputed whether the diagnosis was properly made at the time, Plaintiff was diagnosed with aortic stenosis as a child. 4 Further, in March of 1989 Plaintiff visited Dr. Weinberg at the Gwinnett Pulmonary Group complaining of shortness of breath and chest pain when he exerted himself. Plaintiff smoked one and a half to two packs of cigarettes a day for thirty years and did not engage in regular exercise. After Plaintiff was given an echocardiography, the echo-cardiography report showed á diagnosis of “valvular aortic stenosis with marked left ventricular hypertrophy and normal left ventricular systolic function,” and “minor aortic insufficiency.” Plaintiff also performed a thallium stress-cardiologist exam during wMch he exercised thirteen minutes to exhaustion. The test concluded that coronary artery disease could be ruled out as a cause of Ms symptoms. Plaintiff also underwent a pulmonary examination in 1989, which concluded that sarcoidosis could be ruled out as a cause of Ms symptoms. 5

3. Review of Plaintiffs Medical Claim

Imtially, Plaintiffs claim was reviewed by the Plan’s claims personnel, including Janet McGhee, who was a claims processor, Ginny Dibrell, who was a claims supervisor, and Nick Blanchard, who was a claims manager for Watkins Associated Industries, Inc. Blanchard has a vocational nursing degree from Maricopa College in Arizona and has been licensed as a vocational nurse. They concluded that Plaintiffs 1989 symptoms were referable to his stenotic bicuspid valve and that Ms subsequent surgery in 1993 was therefore based upon a pre-existing condition.

Plaintiff appealed that decision and sought a first review of the claim demal. 6 As a result, Tom Kraft, Director of Health Care Benefits for the Plan, conducted a review. Kraft has over twenty-three years of experience in the. medical claims processing industry, including positions as a claims processor and supervisor of claims processing. Kraft has testified that she conducted her own review of the claim file, including the medical records obtained from Plaintiffs physicians, the Merck Manual, the Stedman’s Medical Dictionary medical reference books, a letter from Dr. Shonkoff dated May 17,1994, and a *1448 letter from Dr. Langford dated April 5, 1994. 7 In Dr. Shonkoffs letter, the doctor concluded that, based upon his review of Plaintiffs medical records, Plaintiff had no “significant symptoms” of aortic stenosis before 1993. Dr. Shonkoff then stated:

I feel that you are morally reprehensible in not agreeing to pay for Mr. Pittard’s lifesaving surgery and it is because of decisions like this that have caused the government to try to step in and overhaul our health care system. In Mr. Pittard’s case, there is no health care crisis. Mr. Pittard has returned to work, has been a productive employee, and I feel he deserves the benefit of the doubt in this case. 8

Dr. Langford’s letter set forth -in relevant part that:

Prior to [November 1993], he did not have “surgically” significant aortic stenosis. According to my records, prior to this time, he had no treatment for aortic stenosis nor symptoms referable to aortic stenosis.... I hope this letter will help clarify matters regarding Mr. Pittard’s insurance coverage. 9

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Cite This Page — Counsel Stack

Bluebook (online)
990 F. Supp. 1444, 1997 U.S. Dist. LEXIS 21226, 1997 WL 817319, Counsel Stack Legal Research, https://law.counselstack.com/opinion/pittard-v-watkins-associated-industries-inc-gand-1997.