Ronald J. Dade v. Sherwin-Williams Company

128 F.3d 1135, 1997 U.S. App. LEXIS 30283, 1997 WL 691036
CourtCourt of Appeals for the Seventh Circuit
DecidedNovember 3, 1997
Docket96-4169
StatusPublished
Cited by38 cases

This text of 128 F.3d 1135 (Ronald J. Dade v. Sherwin-Williams Company) is published on Counsel Stack Legal Research, covering Court of Appeals for the Seventh Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Ronald J. Dade v. Sherwin-Williams Company, 128 F.3d 1135, 1997 U.S. App. LEXIS 30283, 1997 WL 691036 (7th Cir. 1997).

Opinion

ILANA DIAMOND ROVNER, Circuit Judge.

Ronald J. Dade (“Dade”) sued his employer, Sherwin-Williams Company, pursuant to the Employee Retirement Income Security Act (“ERISA”), because Sherwin-Williams terminated certain medical benefits for Dade’s wife Theresa Ann Dade (“Theresa”). The district court granted summary judgment in favor of Sherwin-Williams, largely because Dade failed to respond to SherwinWilliams’ statement of uncontested facts filed under Local Rule 12. Because Dade failed to respond, the rule required the district court to accept as true the facts stated by SherwinWilliams. The district court granted summary judgment because Sherwin-Williams claimed to have paid Dade all benefits due under the policy, and to have given Dade all the notice due under the law. We must now affirm.

I.

Dade was an employee of SherwinWilliams’ who received coverage for himself and his dependents under Sherwin-Williams’ Health Benefits Plan (the “Plan”). In 1984, Theresa developed a cancerous brain tumor which rendered her seriously disabled. She later suffered further injuries in a car accident, and became completely bedridden. The Plan paid a licensed practical nurse to care for Theresa sixteen hours a day, seven days a week from the time of the ear accident in 1986 until January 14, 1994. During that time, however, the parties disputed the extent of coverage to be provided to Theresa, arguing primarily over whether the care she received was skilled nursing care, which was covered under the Plan at varying levels throughout the relevant period, or custodial care, which was never covered by the Plan during the relevant time period.

From 1987 through 1992, the Plan covered all skilled nursing care provided for the treatment of illness or injury. Beginning in 1993, the Plan limited coverage for skilled nursing care to four hours per visit within a 24-hour period, for a maximum of 50 visits per year. Athough the definition of skilled nursing care changed slightly over time, the Plan essentially defined skilled nursing care as services performed by a licensed nurse to assure the safety of the patient and to achieve the medically desired result. The Plan covered only services that were ordered by a physician as part of a homebound patient’s plan of treatment, and only services that were an appropriate level of care for the treatment of the injury or illness. The definition of custodial care also changed over time, but was essentially defined by the Plan as care which primarily assists the covered person in meeting the activities of daily living, which was not primarily skilled nursing care rendered on a continuous basis, which could be rendered other than by a graduate registered nurse or practical nurse, and which was not medically required. From 1993 through 1995, custodial care was defined as services or supplies that are “primarily for the purpose of meeting personal needs such as, but not limited to: help in walking, bathing, dressing,' eating, prevention of bed sores, patient positioning, preparation of special diets, and supervision or administration of medication which can usually be self-administered and which does not entail or require continuous attention or monitoring by trained medical or paramedical personnel.”

The Plan also provided that in disputed cases, the Plan administrator, here Provident Life and Accident Insurance Company (“Provident”), reserved the right to make a final determination about whether services constituted skilled nursing care or custodial care. The Plan also provided during the relevant time period that Sherwin-Williams, as the Plan sponsor, reserved the right to “terminate, suspend, withdraw, amend or modify the Plan, covering any active Employee or current or future retiree, in whole or in part at any time.” From 1991 through 1995, the Plan provided that Provident had “final discretionary authority to determine eligibility for benefits or to construe the terms of the Plan for claims purposes only.” Aso, beginning in 1992 and continuing through 1995, the Plan established a case management services program. The purpose of this program *1138 was to allow a case manager to determine whether a plan of medical treatment was appropriate in cases where the covered person suffered a severe injury- or illness. Healthcare COMPARE Corporation (“HCCC”) administered this program from 1993 through 1995. Dade received notices of changes in coverage through summary plan descriptions (“SPD”). Sherwin-Williams periodically distributed the SPDs to all of its employees between 1987 and 1995, and these SPDs are identical to the written instrument that established the Plan. According to Sherwin-Williams, Dade received SPDs that described all of the provisions of the Plan that are at issue here.

In 1987, Provident notified Dade that it had reviewed notes from Theresa’s private duty nurse and information from her doctor and determined that she was receiving custodial care rather than skilled nursing care. On that basis, Provident stated that the Plan would no longer cover the cost of the private duty nurse. Dade appealed this decision, and Provident reinstated coverage for nursing care, retroactive to the date the coverage had been terminated. In 1992, Provident again suspended payment of benefits, and again reinstated benefits retroactively after Dade challenged the decision. In August 1993, HCCC left Dade a voice mail telling him that it was terminating coverage for Theresa’s licensed practical nurse as of June 1993. HCCC then sent a letter explaining that the services provided by the nurse were custodial in nature rather than skilled nursing, and that the services could be provided by a family member or any responsible adult. Accordingly, HCCC recommended an alternative plan of nursing care allowing three visits by a registered nurse over the following month, and then monthly skilled nursing visits thereafter.

Dade again appealed the decision, and HCCC replied that it had completed its review and reaffirmed its decision not to certify skilled nursing care for Theresa at the level at which it had been provided. Provident concurred with this judgment, but paid Dade for the care that had been provided through the date that he had first received notice of the termination of benefits. SherwinWilliams then voluntarily undertook its own review of the Dades’ claim-for nursing care coverage and agreed to pay all claims through January 14,'1994, but not past that date. After that point, Provident paid only in accordance with its determination that Theresa required only one visit per month from a skilled nurse.- Theresa died on November 21,1995.

In his complaint, Dade contended that Sherwin-Williams repeatedly attempted to terminate coverage without explaining its decision or notifying him of his right to appeal, in violation of ERISA. He also contended that Sherwin-Williams failed to notify him of any changes in the Plan, and refused to provide him with a copy of the on-site review that Sherwin-Williams used as a basis for terminating Theresa’s nursing services. The district court noted that it was difficult to discern exactly what claims Dade sought to bring under ERISA. Although Dade cited several sections of the ERISA statute, including 29 U.S.C. §§ 1024(b)(4), 1102(b)(3), 1104

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Bluebook (online)
128 F.3d 1135, 1997 U.S. App. LEXIS 30283, 1997 WL 691036, Counsel Stack Legal Research, https://law.counselstack.com/opinion/ronald-j-dade-v-sherwin-williams-company-ca7-1997.