Schachner v. Blue Cross & Blue Shield

77 F.3d 889, 1996 U.S. App. LEXIS 3958, 1996 WL 99295
CourtCourt of Appeals for the Sixth Circuit
DecidedMarch 8, 1996
DocketNo. 94-4217
StatusPublished
Cited by23 cases

This text of 77 F.3d 889 (Schachner v. Blue Cross & Blue Shield) is published on Counsel Stack Legal Research, covering Court of Appeals for the Sixth Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Schachner v. Blue Cross & Blue Shield, 77 F.3d 889, 1996 U.S. App. LEXIS 3958, 1996 WL 99295 (6th Cir. 1996).

Opinion

BAILEY BROWN, Circuit Judge.

In this Employee Retirement Income Security Act (ERISA) case,1 Chaim Schachner sued Blue Cross and Blue Shield of Ohio (“BCBSO”) after it refused to pay for cardiac rehabilitation therapy (“cardiac rehab”) he received after undergoing a coronary surgical procedure called angioplasty. Schachner contends that the costs of cardiac rehab are covered under the plain language of the insurance certificate BCBSO issued to him. BCBSO counters that the language of the certificate is ambiguous, and that extrinsic evidence proves the parties did not intend to cover cardiac rehab. The district court agreed with BCBSO and granted it summary judgment. Schachner appeals.

Schachner also appeals from the district court’s several orders denying his attempts to establish himself as the representative of a class of several similarly situated BCBSO insureds. Additionally, Schachner appeals from the court’s dismissal of his various state law claims as pre-empted by ERISA.

For the reasons set forth below, we REVERSE the court’s grant of summary judgment on the ERISA claims, and VACATE the court’s orders disposing of Schachner’s attempts to have a class certified. We AFFIRM the district court’s dismissal of Scha-chner’s individual state law claims, but VACATE the dismissal of state law claims which could be maintained on behalf of potential class members whose insurance certificates are not controlled by ERISA. We REMAND this case to the district court for further proceedings consistent with this opinion.

I. FACTS

Schachner is a partner in and an employee of the Dallas Shoe Warehouse Co. (“the company”), a partnership specializing in retail shoe sales in Cleveland, Ohio. The company is a member of a group of Cleveland-area [892]*892businesses called the Council of Small Enterprises (“COSE”).2 The company offered its employees health insurance plans which COSE had negotiated with BCBSO.

In May of 1989, Schachner underwent a coronary surgical procedure called angioplasty. Afterward, Schachner’s physician prescribed for him a standard cardiac rehab program. Schachner participated in thirty-three treatment sessions over a five-month period. His doctor described the sessions as “consist[ing] of supervised exercise training to strengthen the muscles of the heart and the function of the circulatory system, surveillance of risk factors, appropriate counsel-ling, and monitoring of progressive exercise to return Mr. Schachner to his pre-sympto-matic level of function.” The nurse who supervised the treatments said that the “sessions consisted of supervised training and exercise to strengthen the cardiovascular system by improving the function of the circulatory system.”

BCBSO paid Schachner’s claims for the angioplasty procedure, but denied his claims for cardiac rehab on the ground that cardiac rehab is not a covered service under his insurance certificate (“the certificate”). Schachner subsequently filed this suit, asserting claims under ERISA3 and on state law grounds, on his own behalf and as a representative of a putative class of BCBSO insureds who have been denied coverage for cardiac rehab under similar insurance certificates.

Schachner’s certificate includes, in a section headed “Health Care Benefits,” a subheading called “Therapy Services.” According to the certificate, “Therapy Services” includes radiation therapy, chemotherapy, dialysis treatments, treatment by physical means, respiratory and pulmonary therapy, and inpatient speech and occupational therapy. The paragraph addressing treatment by physical means states:

Treatment by Physical Means — The treatment given to relieve pain, restore maximum function and prevent disability following disease, injury or loss of a body part. Such services include physical treatments, hydrotherapy, heat or similar modalities, physical agents, hyperbaric therapy, bio-mechanical and neurophysiological principles and devices.

While the certificate specifically lists several “Exclusions,” cardiac rehab is not among them.

Schachner contends that his cardiac rehab sessions fit squarely within the definition of Treatment by Physical Means. He relied on the affidavit of his physician, in which the doctor states:

I have found cardiac rehabilitation services, such as those prescribed by me, to be an effective method of restoring function to the heart and circulatory system, combating heart disease, preventing future incidents of acute coronary distress, important adjunction therapy to help cardiac patients resume normal function as promptly as possible, and an effective method of improving of cardiac risk factors to help retard disease progression.

BCBSO, however, claims that it must pay for cardiac rehab only when it is separately listed as a covered service in the insurance certificate. It submitted to the district court copies of insurance certificates with separate listings for cardiac rehab.

II. ANALYSIS

A. The contract language at issue is not ambiguous.

1. The appropriate law to be applied

We review the district court’s grant of summary judgment and denial of partial summary judgment de novo, applying the same test as the district court. E.g., Pierce v. Commonwealth Life Ins. Co., 40 F.3d 796, 800 (6th Cir.1994). Summary judgment is proper “if the pleadings, depositions, answers to interrogatories, and admissions on file, together with the affidavits, if any, show that there is no genuine issue as to any material [893]*893fact and that the moving party is entitled to a judgment as a matter of law.” Fed.R.Civ.P. 56(c).

We can resolve most of this appeal by determining whether the district court erred in concluding that the meaning of the term “Treatment by Physical Means” is ambiguous. We review a district court’s conclusions regarding ambiguity in contract language de novo. Wulf v. Quantum Chem. Corp., 26 F.3d 1368, 1376 (6th Cir.) (citing Boyer v. Douglas Components Corp., 986 F.2d 999, 1003 (6th Cir.1993)), cert. denied, - U.S. -, 115 S.Ct. 667, 130 L.Ed.2d 601 (1994). Contract language is ambiguous if it is subject to two reasonable interpretations. Id. (citing Smith v. ABS Indus., 890 F.2d 841, 846-47 n. 1 (6th Cir.1989)). If a court determines that a contract provision is ambiguous, then it “may use traditional methods of contract interpretation to resolve the ambiguity, including drawing inferences and presumptions and introducing extrinsic evidence.” Boyer, 986 F.2d at 1005.

Courts may not, however, use extrinsic evidence to create an ambiguity. Rather, the ambiguity must be patent; that is, apparent on the face of the contract. In

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Bluebook (online)
77 F.3d 889, 1996 U.S. App. LEXIS 3958, 1996 WL 99295, Counsel Stack Legal Research, https://law.counselstack.com/opinion/schachner-v-blue-cross-blue-shield-ca6-1996.